ORAL    DISEASES 


SURGERY. 


^^  A/,  /^tr^^yt, 


A  TREATISE 


DISEASES  AND  SURGERY 


MOUTH,    JAWS 


ASSOCIATE    PARTS. 


BY 


JAMES  E.  GAERETSOE",  M.D.,  D.D.S., 

LATE   LECTURER   OX   ANATOMY    AND   SURGERY   IX   THE    PHILADELPHIA    SCHOOL   OF   ANATOMY;    UTE 
PROFESSOR   OP   THE    PRINCIPLES    AND    PRACTICE    OF  OEXERAL   SURGERY   IN   THE    PHILADEL- 
PHIA DENTAL   COLLEGE;    MEMBER  OF  THE    PHILADELPHIA  PATHOLOGICAL   SOCIETY; 
MEMBER   OF  THE   ODONTOGRAPHIC    SOCIETY   OF  PENNSYLVANIA,  ETC.  ETC. 


f  tT«s!tt' atfd  with  ^\tt\  llatf;s  antl  nMtnftoujsi  Woo^-ruts/. 


PHILADELPHIA: 

J.    B.    LIPPINCOTT     &     CO. 

1869. 


Entered,  according  to  Act  of  Congress,  in  the  year  1869,  by 

J.    B.    LIPriNCOTT    &    CO., 

In  the  Clerk's  OiBce  of  the  District  Court  of  the  United  States   for   the 
Eastern  District  of  Pennsylvania. 


l/UD 


PREFACE. 


In  the  fulfillment  of  many  promises  made  from 
time  to  time  to  his  students  and  other  friends,  the 
author  has  prepared  the  following  pages,  as  embody- 
ing the  results  of  his  observations  and  experiences 
during  a  somewhat  extended  practice  in  that  branch 
of  the  profession  to  which  it  specially  relates. 

With  the  hope  that  the  volume  will  be  a  useful 
text-book  in  assisting  the  student  to  prepare  for  the 
responsible  duties  of  the  profession,  and  a  reliable 
guide  to  the  intelligent  practitioner,  it  is  herewith 
offered  to  the  attention  both  of  those  who  are  about 
to  enter  the  field  of  their  labors  and  of  those  who, 
though  more  familiar  with  the  practical  duties  there- 
of, may  desire  to  acquaint  themselves  more  fully 
with    the  latest   methods   of  practice. 

That  the  work  may  prove  a  source  of  benefit  to 
his  fellow-beings  is  the  highest  hope  concerning  it  of 

The   Author. 

(V) 


ACKNOWLEDGMENT. 


The  first  three  hundred  pages  of  this  work  were 
scarcely  through  the  press  when  the  author  received 
the  grateful  encouragement  of  finding  it  adopted  as  a 
text-book  by  several  of  the  oldest  and  most  influ- 
ential of  the  Dental  Colleges  of  the  United  States; 
for  such  a  manifestation  of  interest  and  confidence 
he   would  express   his    appreciation. 

To  S.  S.  White,  Esq.,  who,  with  great  generosity, 
placed  at  the  command  of  the  publishers  all  of  his 
large  collection  of  cuts  illustrative  of  dental  sur- 
gery, thanks  are  especially  due,  as  this  kindness  has 
done   much   to   enhance    the    value  of    the   work. 


(vii) 


CONTENTS. 


CHAPTEE  I. 

PAGE 

Surgical  Anatomy  of  the  Mouth  and  Face 17 

CHAPTEK  II. 
The  Mouth 44 

CHAPTEPv  III. 
Fifth  Pair  of  Nerves 63 

CHAPTEK  IV. 
Dentition 79 

CHAPTER  V. 

Associate  Lesions  of  First  Dentition 88 

CHAPTEE  VI. 

Anomalies  oT  Second  Dentition  and  their  Surgical  Eelations 116 

CHAPTEE  VII. 
The  Teeth  and  their  Diseases — Alveolar  Abscess 140 

CHAPTEE  VIII. 
The  Teeth  and  their  Diseases — Trismus 147 

CHAPTEE  IX. 
The  Diseases  of  the  Teeth — Caries 163 

CHAPTEE  X. 

Diseases  of  the  Teeth — Odontalgia 201 

(ix) 


X  CONTENTS. 


CHAPTER  XI. 

PAGE 

Diseases  of  the  Teeth — Salivary  Calculus 213 


CHAPTER  XII. 

Diseases  of  the  Teeth — Denudation 221 

CHAPTER  XIII. 
The  Extraction  of  Teeth 223 

CHAPTER  XIV. 

General  Remarks  on  Extraction 234 

CHAPTER  XV. 

General  Anaesthesia 242 

CHAPTER  XVI. 
General  Ana?sthesia 252 

CHAPTER  XVII. 
Salivary  Fistule 267 

CHAPTER  XVIII. 
The  Tonsil  Glands 272 

CHAPTER  XIX.  , 

The  Gums  and  their  Diseases 280 

CHAPTER  XX. 
Caries  of  the  Maxillse 303 

CHAPTER  XXI. 
Necrosis 309 

CHAPTER  XXII. 
The  Tumors  of  the  Mouth 327 

CHAPTER  XXIII. 
Exostosis  and  Subacute  Inflammatory  Tumors 353 


CONTENTS.  xi 


CHAPTER  XXIV. 

Page 

The  Epulides 362 


CHAPTER  XXV. 
Osteo-sarcoma 37I 

CHAPTER  XXVI. 
Osteo-carcinoma 386 

CHAPTER  XXVII. 
Epithelioma 395 

CHAPTER  XXVIII. 

Tumors  of  Parts  Associated  with  the  Mouth 405 

CHAPTER  XXIX. 
The  Antrum  of  Highmore,  and  its  Diseases 419 

CHAPTER  XXX. 
Neuralgia 435 

CHAPTER  XXXI. 

Wounds  of  the  Mouth  and  Associate  Parts 472 

CHAPTER  XXXII. 
Ozsena 497 

CHAPTER  XXXIII. 

Fractures  of  the  Maxillary  Bones 510 

CHAPTER  XXXIV. 

Dislocation  of  the  Inferior  Maxilla 524 

CHAPTER  XXXV. 
Operations  upon  the  Lips  and  Cheek 531 


xii  CONTENTS. 

CHAPTER  XXXYI. 

PAGE 

Operations  upon  the  Lips  and  Cheek 548 

CHAPTER  XXXVII. 

The  Tongue  and  its  Diseases 562 

CHAPTER  XXXVIII. 
The  Aphthte COO 

CHAPTER  XXXIX. 

Ranula 621 

CHAPTER  XL. 

Palatine  Defects  and  their  Treatment 633 

CHAPTER  XLI. 

Obturators 652 

CHAPTER  XLII. 

Resection  of  the  Maxillary  Bones 679 


LIST   OF   ILLUSTRATIONS. 


FIG.  PAGK 

1.  Front  and  lateral  region  of  the  skull 18 

2.  Superior  maxillary  bone  of  the  left  side — outer  view  ..  21 

3.  Superior  maxillary  bone  of  the  left  side — inner  view 21 

4.  Inferior  maxillary  bone 26 

5.  Posterior  view  of  the  right  palate  bone 29 

6.  Exterior  view  of  the  right  palate  bone 29 

7.  The  vomer — view  of  left  side 31 

8.  Articular  relations  of  vomer 32 

9.  Position  and  relations  of  turbinated  bones 33 

10.  Ethmoid  bone — general  view 34 

11.  The  sphenoid  bone — upper  view 36 

12.  The  sphenoid  bone — front  view 37 

13.  Anterior  view  of  the  left  nasal  bone 40 

14.  Outer  view  of  the  right  malar  bone 41 

15.  External  view  of  the  right  lachrymal  bone 42 

16.  The  hyoid  bone 43 

17.  Muscles  of  the  head  and  neck 46 

18.  Arteries  of  the  face ; 47 

19.  The  common  carotid,  with  its  divisions 48 

20.  Nerves  of  the  face 49 

21.  Veins  of  the  head  and  neck 51 

22.  Sectional  view  of  the  nose,  mouth,  pharynx 53 

23.  Upper  surface  of  the  tongue 55 

24.  Diagram  of  the  papillae  of  the  tongue,  moderately  magnified 56 

25.  PapilliB  of  the  tongue,  highly  magnified 56 

26.  Vertical  section  of  the  articulation  of  the  lower  jaw 61 

27.  External  view  of  the  temporo-maxillary  articulation 61 

28.  Trifacial  division  and  ganglia 64 

29.  Superior  maxillary  nerve 67 

30.  Inferior  maxillary  nerve 69 

31.  Ophthalmic  ganglion — the  outer  part  of  the  right  orbit  removed 72 

(  xiii ) 


xiv  LIST  OF  ILLUSTBATIONS. 

Fia.  PAQB 

32.  View  of  the  spheno-palatine  ganglion,  the  outer  wall  of  the  left  nasal 

cavity,  and  the  olfactory  nerve 73 

83.  General  appearance  of  the  first  set  or  milk  teeth 86 

34.  Forms  of  chisels  used  in  dentistry 188 

35.  File,  with  carrier 189 

36.  Hoe  excavators  and  modifications 190 

37.  Hatchet  excavators  and  modifications 190 

38.  Eose  drills  and  spear  drills 191 

39.  Instruments   employed    in   introducing,  condensing,  and  polishing 

gold  and  tin  fillings 195 

40.  Instrunifints  employed  in  removing  tartar  from  teeth 219 

41  and  42.  Denudation 221 

43  and  44.  Diagram  of  teeth 223 

45.  Incisor  forceps  for  superior  jaw 225 

46.  Incisor  forceps  for  inferior  jaw 225 

47.  The  Maynard  forceps — right  and  left 225 

48.  The  ordinary  molar  forceps — right  and  left 226 

49.  Maynard  forceps  for  inferior  molars 227 

50.  The  Physick  forceps 227 

51.  Forceps  for  wisdom  teeth 228 

52.  The  elevator — various  forms 229 

53.  Relation  of  fractured  roots  to  alveolar  line 230 

54.  The  screw 231 

55.  Spray  apparatus — hand  instrument 240 

56.  Spray  apparatus — foot  instrument 241 

57.  Salivary  fistule — from  life 267 

58.  The  tonsil  glands 272 

59.  Hypertrophied  tonsil 274 

00.  View  of  the  air-tubes 277 

yi.  View  of  gums  inflamed  by  vulcanite  plate 294 

62.  View  of  case  of  congenital  hypertrophy 295 

63.  View  of  chronic  ulitis,  with  recession 297 

64.  Appearance  of  patient  with  phosphor-necrosis 319 

65.  Sequestrum  after  measles 323 

66.  Odontocele 334 

67.  Dental  tumor 339 

68.  Dental  tumor 340 

69.  Dental  tumor 341 

70.  Microscopic  section 342 


LIST  OF  ILLUSTRATIONS.  XV 

FIO.  PAGH 

71.  Antral  cyst 349 

72.  Secondary  cyst  of  the  antrum 351 

73.  Hyperostosis 358 

74.  Osseous  tumor 360 

75.  Small  epulo-fibroid  tumor — from  life 364 

76.  Epulo-erectile  tumor 365 

77  and  78.  Epulic  tumors  368 

79.  Section  of  bone  as  first  and  afterward  made 369 

80.  Fibrous  epulis  of  upper  jaw 370 

81.  Osteo-sarcoraatus  tumor 385 

82.  Cysto-sarcoma 385 

88.  Epithelial  tumor  of  lip .397 

84.  Epithelial  ulcer  of  gum 398 

85.  Epithelial  ulceration  of  lip  and  tongue 399 

86.  Small  Sebaceous  tumor,  showing  its  sacculated  condition 406 

87.  Cartilaginous  cyst 408 

88.  Lobulated  lipomatous  tumor — after  Miller 409 

89.  Microscopic  structure  of  an  adipose  tumor  (Bennet) 410 

90.  View  of  fatty  tumor  removed  from  under  the  tongue  (Listen) 410 

91.  Venous  tumor 413 

92.  Crossed  or  knotted  bandage 474 

93.  Barton's  bandage 515 

94.  Gibson's  bandage 516 

95.  The  yard  bandage 517 

96.  One  of  Dr.  Gunning's  splints 518 

97.  Dr.  Gunning's  second  splint 518 

98.  Dr.  Gunning's  third  splint 519 

99.  Dr.  Gunning's  fourth  splint 519 

100.  Complete  Dislocation  of  jaw 524 

101.  Manner  of  reducing  a  luxated  jaw 528 

102.  Vertico-mental  sling  or  cap 529 

103.  Mouth-stretcher 553 

104.  A  microscopic  view  of  cancer-cells 576 

105.  Palatine  defect 660 

106.  Obturator 661 

107.  Palatine  defect G62 

108.  Obturator 663 

109.  Palatine  defect 664 

110.  Obturator 665 


xvi  LIST  OF  ILLUSTRATIONS. 

TIG.  PAGE 

111.  Palatine  defect 666 

112.  Oral  defect 667 

113.  Obturator 668 

114.  The  face,  without  nose 671 

115.  Internal  view  of  superior  arch 672 

116  and  117.  Nose,  with  attachments 674 

118.  The  face,  with  nose 676 

119.  Mouth-stretcher  applied 687 

120.  View  of  position  of  inferior  maxillary  nerve 690 


PLATES. 


I.  Anomalies  in  dentition 127,  128 

II.  Anomalies  in  dentition 130,131 

III.  Anomalies  in  dentition 133,  134 

IV.  Dental  tumor — with  microscopic  appearance  of 136 

V.  Anomalies  in  dentition 137,139 

VI.  View  of  the  anatomy  of  the  side  of  the  face  and  some  of  the  opera- 
tions practiced  on  it 271 

VII.  A  view  of  the  operations  performed  on  the  trachea 279 

VIII.  Appearance  and  position  of  some  of  the  tumors  seen  about  the 

neck 404 

IX.  Hare-lip  and  other  conditions 548 

X.  The  operations  of  cheiloplasty  and  genioplasty 556 

XI.  Rhinoplastic  and  cheiloplastic  operations 559 

XII.  .Operations  practiced  on  the  tongue  and  tonsils 595 

XIII.  Eesections  of  the  upper  and  lower  jaws 681 


DISEASES  OF   THE   MOUTH 


ASSOCIATE   PARTS. 


CHAPTER    I. 

SURGICAL  ANATOMY   OF   THE    MOUTH    AND    FACE. 

In  a  work  on  oral  diseases  and  surgery,  a  source  of  ready  and 
accurate  reference  to  parts  involved  would  seem  to  be  an  essential. 
With  such  view  we  map  out,  as  accurately  as  the  photograph  and 
pencil  may  represent  nature,  all  such  parts  as,  surgically,  we  may 
have  to  deal  with  or  comprehend.  As — unless  with  the  very  expe- 
rienced— it  is  always  desirable  to  precede  an  operation  on  the  living 
with  a  test  performance  on  the  dead,  so  with  the  student  it  is  as 
desirable  to  found  the  comprehension  of  any  pathological  perver- 
sion on  an  understanding  of  normal  characteristics. 

In  presenting  these  photographs  of  the  various  parts  associated 
with  oral  surgery,  we  add  the  suggestion  that  the  bones  represented 
be  procured  and  laid  carefully  away  in  the  cabinet :  the  assistance 
of  their  silent  expressions  will  be  found  invaluable.  So  far  as  the 
soft  parts  are  concerned,  one  may  either  possess  them  in  alcohol,  or, 
what  is  even  better,  where  it  can  conveniently  be  done,  is  to  make 
it  a  point  to  yearly  dissect  them. 

In  Fig.  1  the  lateral  aspect  of  the  face  is  seen  to  form,  almost 
accurately,  an  oblong  square.  A  modification  on  such  a  square, 
however,  will  be  found  to  exist  in  the  case  of  the  child,  where 
the  ramus  of  the  inferior  maxillary  bone  is  at  a  more  obtuse  angle 
with  the  body;  also  in  the  case  of  an  adult  with  prominent  os 
frontis.     In  either  of  these  cases  the  lateral  aspect  is  triangular. 

2  (H) 


18  ORAL   DISEASES  AND  SURGERV. 

Bounded  circumferentially  by  the  supraorbital  ridge  of  the  frontal 
bone,  the  nasal  process  of  the  superior  maxillary,  and  the  malar 
bones,  we  find  a  pyramidal  cavity,  the  orbital,  for  the  accommoda- 
tion of  the  organ  of  sight.  Looking  at  the  natural  bone,  no  less  than 
seven  pieces  are  observed  entering  into  the  composition  of  this  cavity, 
some  of  which  pieces  in  their  relations  closely  affect  some  of  the 
proceedings  in  oral  surgery :  for  example,  it  will  be  seen  that  a  large 
portion  of  the  floor  of  this  cavity  is  made  up  by  a  process,  the  or- 
bital, which  is  a  part  of  the  superior  maxilla;  glancing  at  the  natu- 

FiG.  1. — Front  aisD  Lateral  Region  of  the  Skull. 


The  SKULl,  seen  partlt  in  front  and  on  the  right  side.  1,  frontal  bone ;  2,  parietal 
bone;  3,  temporal  bone,  its  squamous  portion;  4,  the  sphenoid  bone,  temporal  surface  of 
its  great  wing;  5,  ethmoid  bono,  its  orbital  surface;  6,  superior  maxillary  bone ;  7,  malar 
bone ;  8,  lachrj'mal  bone ;  9,  nasal  bone ;  10,  inferior  maxillary  bone,  a,  orbital  plate  of 
the  frontal  bone ;  b,  temporal  surface ;  c,  orbital  surface  of  the  great  wing  of  the  sphenoid 
bone;  d,  mastoid  portion  of  the  temporal  bone ;  «,  orbital  surface  of  the  malar  bone; 
/,  orbital  plate  of  the  superior  maxillary  bone ;  g,  infraorbital  foramen ;  ft,  mental  fora- 
men; J,  symphysis  ;  J,  ramus ;  A:,  coronoid  process;  ?,  neck  supporting  the  condyle;  m, 
angle;  n,  lachrymo-nasal  duct. 

ral  bone,  it  will  be  seen  that  this  process  constitutes  as  well  the  roof 
of  the  antral  sinus ;  it  will  also  be  found  to  be  a  very  thin  plate  ;  and 
capable  of  being  easily  elevated  or  depressed,  according  as  any  press- 
ure might  be  brought  upon  it  from  below  or  above ;  constituting  a 
source  of  support  to  the  eye,  it  will  also  be  seen  that,  where  it  is 
possible,  it  should  be  left  undisturbed  in  operations  demanding  ex- 
ensive  interference  with  the  bone  of  which  it  is  a  part.     At  the 


JNAT03IY  OF   THE  MOUTH  AND   FACE.  19 

inner  inferior  aspect  of  the  cavity  a  groove  will  be  observed,  the 
lachrymal,  being  the  entrance  to  a  canal,  the  ductus  ad  nasum,  carry- 
ing the  tears  from  the  orbit  to  the  inferior  meatus ;  the  outer  wall 
of  this  canal,  which  it  is  most  important  to  maintain  patulous,  is 
made  up  by  the  inner  face  of  the  nasal  process,  another  portion  of 
the  superior  maxillary  bone.  Diseases  of  the  sinus  not  unfrequently 
react  on  the  eye,  and  to  such  an  extent,  that  blindness  of  several 
months'  standing  has  been  cured  by  the  extraction  of  a  diseased 
tooth-root  which  had  affected  the  antrum  to  its  engorgement. 
Closure  of  the  lachrymal  canal  is  almost  certain  to  occur  if  the 
nasal  process  becomes  inflamed,  and  such  inflammation  I  have  fre- 
quently met  with  as  the  result  of  an  odontocele. 

Immediately  below  the  inferior  boundary  of  the  orbit  is  seen  a 
foramen,  the  infraorbital,  for  transmission  of  the  infraorbital  branches 
of  the  fifth  nerve.  Passing  a  bristle  through  this  foramen,  it  is  seen 
to  emerge  in  the  groove  marked  on  the  floor  of  the  orbit, — the  infra- 
orbital groove  in  which  the  nerve  lies  in  its  passage  outward.  This 
groove  and  this  canal  are  both  in  the  maxillary  bone,  and  are  alike, 
Avith  the  ductus  ad  nasum,  influenced  by  its  diseases. 

The  canine  fossa,  seen  back  of  and  above  the  canine  tooth,  has,  as 
its  floor,  a  thin  plate  of  bone,  which  is  the  external  face  of  the  antrum, 
and  through  which,  if  it  should  be  found  necessary,  the  cavity  may 
be  easily  entered. 

The  tuberosity  of  the  bone,  occupied  in  part  by  the  wisdom  tooth, 
and  marked  for  the  attachment  of  the  buccinator  muscle,  is  a  point 
of  surgical  interest, — it  being  not  at  all  uncommon  to  have  necrosis 
of  this  portion  of  the  bone,  the  result  of  an  ostitis,  induced  and  kept 
up  by  an  imprisoned  dens  sapientijB.  Standing,  as  is  seen,  at  an 
angle,  and  tubercle-like,  it  is  plainly  evident  that  neither  deformity 
nor  harm  would  result  from  its  separation  as  a  sequestrum. 

The  alveolar  processes  are  remarked  to  constitute  quite  a  large 
part  of  both  the  superior  and  inferior  maxillary  bones.  These  pro- 
cesses, vascular  and  spongy,  subjected  to  all  irritations  residing  in 
diseased  teeth,  are,  without  doubt,  more  subject  to  take  on  patho- 
logical action  than  any  other  portion  of  the  ossa  corpora.  From 
the  alveolo-dental  periosteum  spring  epulic  outgrowths  of  various 
signification.  Sarcomatous  degeneration  finds  here  a  favorite  seat: 
simple  and  compound  cysts  are  very  familiar,  degenerative  ostitis 
is  not  uncommon,  while  abscess  is  found  in  almost  every  mouth. 
The  mental  foramen,  seen  upon  the  inferior  maxilla,  a  little  anterior 
to  the  middle  of  the  body,  is  the  outlet  of  a  canal  traversing  the 


20  ORAL   DISEASES  AND   SURGERY. 

center  of  the  bone,  and  conducting  beneath  the  teeth  the  dental 
artery  and  nerve.  The  size,  general  character,  and  inlet  of  this 
canal  should  be  observed,  as  not  unfrequently  injuries  to  the  artery 
require  that  the  canal  should  be  plugged,  either  as  foramina  are 
concerned,  which  exist  beneath  each  tooth,  or  as  the  channel  proper 
is  interfered  with  in  operations  for  tumors  or  sequestra. 

Neuralgia  of  some  of  the  peripheries  of  the  inferior  dental  nerve 
makes  necessary,  occasionally,  its  section  within  the  canal.  To  get 
at  this  nerve,  requires  either  that  we  shall  extract  some  tooth,  and 
make  the  section  from  the  base  of  the  socket,  or  otherwise  that  a 
trephine  shall  be  used  from  the  outside.  The  easiest  mode  of  per- 
forming such  operations  is  to  be  observed,  as  relation  is  had  to 
locations  and  character  of  bone. 

The  relationship  of  the  teeth  to  their  spongy  processes  is  a  mat- 
ter which  should  receive  close  attention,  the  operation  for  their 
extraction  being  a  very  common  one.  These  processes,  if  examined 
in  a  number  of  bones,  will  be  found  greatly  to  vary  in  character :  in 
some  being  of  such  loose  structure  that  the  teeth  are  capalde  of  the 
easiest  separation ;  in  other  instances  being  so  firm  and  unyielding 
that  it  is  quite  a  matter  of  impossibility  to  make  such  extraction 
without  more  or  less  fracture. 

The  number  and  shape  of  the  roots  of  the  teeth  are  to  be  ex- 
amined. A  knowledge  of  their  curves  contributes  much  to  an  ease 
in  their  removal.  Indeed,  no  one  but  the  experienced  can  appreciate 
how  much  easier  it  is  to  remove  the  teeth  with  than  without  such 
knowledge. 

The  nasal  bones,  forming  in  their  conjunction  the  nasal  arch, 
should  be  examined  in  their  relation  to  each  other  and  to  the  neigh- 
boring pieces.  Articulating  with  the  perpendicular  plate  of  the 
ethmoid,  it  has  not  unfrequently  happened  that  the  depression  of 
this  arch  from  a  blow  has  carried  the  crista  galli  into  the  sub- 
stance of  the  brain,  and  thus  produced  the  most  serious  if  not  fatal 
consequences.  The  nasal  bones  are  frequently  the  seat  of  syijhilitic 
degeneration.  Their  destruction  compels  the  falling  in  of  the  nasal 
arch,  thus  yielding  the  flattening  of  the  bridge  occasionally  ob- 
served,— one  of  the  most  repulsive  of  deformities. 

The  incisive  fossa,  observed  between  the  anterior  nasal  spine  and 
central  incisor  teeth,  frequently  yields  its  floor  to  the  ravages  of 
necrosis.  There  would  seem  to  be  here  less  vital  resistance  than  in 
other  parts  of  the  bone,  as  necrosis  of  a  tooth  is  almost  necessarily  as- 
sociated with  necrosis  of  the  superficial  surface  of  its  alveolus.    This 


AXAT03IY  OF  THE  MOUTH  AND   FACE. 


21 


plate  is,  however,  quite  thin,  and  its  loss  seldom  seems  of  much 
consequence. 

The  position  of  a  groove  for  the  passage  of  the  facial  artery  is  to 
be  noticed,  as  location  and  distance  from  the  angle  of  the  jaw  are 
concerned, — the  control  of  hemorrhage  about  the  lips  and  cheeks 
being  here  secured  through  simple  pressure  on  the  artery  as  it  passes 
over  the  bone. 

With  such  general  observation  of  the  surgical  features  of  the 
bones  in  their  conjunction,  we  pass  to  a  more  accurate  comprehen- 
sion, by  examining  the  pieces  in  their  separate  capacities. 


Pigs.  2  and  3. — Superior  Maxillary  Bone. 


Superior  maxulart  bone  of  the  left  side, 
outer  view.  1,  body;  2,  tuberosity;  3,  alve- 
olar border;  4,  orbital  plate;  5,  nasal  process  ; 
6,  nasal  notch;  7,  nasal  spine;  8,  lachrymal 
groove  ;  9,  entrance  of  the  infraorbital  canal ; 
10,  infraorbital  foramen ;  11,  orifices  of  the 
posterior  dental  canals  ;  12,  malar  process ; 
13,  articulation  for  the  internal  angular  pio- 
cess  of  the  frontal  bone ;  14,  incisor  teeth ; 
15,  canine  tooth ;  16,  premolar  teeth ;  17,  large 
molar  teeth. 


Superior  maxillary  bone  of  the  left  side, 
inner  view.  1,  nasal  surface  of  the  body ;  2, 
surface  for  the  palate  bone ;  3,  alveolar  bor- 
der ;  4,  orbital  plate ;  5,  nasal  process ;  6, 
ridge  for  the  articulation  of  the  turbinated 
bone;  7,  nasal  spine;  8,  groove  contributing 
to  form  the  lachrymo-nasal  duct;  9,  maxil- 
lary sinus ;  10,  palate  plate,  its  articulating 
border  for  the  right  maxillary  bone ;  11,  in- 
cisive foramen  continuous  with  the  naso- 
palatine canals;  12,  tuberosity;  LS,  articular 
extremity  for  the  internal  angular  process 
of  the  frontal  bone ;  14,  incisor  teeth ;  15, 
canine  tooth;  16,  premolar  teeth;  17,  large 
molar  teeth. 

Glancing  hastily  at  the  superior  maxillary  bone,  it  seems  like 
a  quadrilateral,  moi'e  or  less  irregular,  solid  piece.  Looking  at  it 
closelv,  and  from  the  surgical  stand-point,  we  find  it  to  consist  of  a 
series  of  processes,  so  grouped  together  as  to  form,  or  rather  inclose, 
a  cavity  so  large  that  the  apparently  solid  body  is  found  to  be 
simply  a  shell.  This  cavity  of  the  shell  is  called  the  maxillary 
sinus,  or  the  antrum  of  Highmore.     It  is  a  very  irregular  cavity. 


22  ORAL  DISEASES  AND  SURGERY. 

differing,  indeed,  in  shape  in  almost  every  bone  ;  generally,  how- 
ever, being  found  as  a  single  cave,  but  not  unfrequently  divided  into 
two  or  more  by  septi  of  bone  vertically  placed.  How  far,  in  the 
mean  of  cases,  the  cave  is  found  to  run  forward  and  how  far  back- 
ward, what  in  the  mean  of  cases  is  its  relation  to  the  roots  of  the 
various  teeth,  which  of  its  boundaries  are  the  thinnest,  are  matters 
worthy  of  l)eing  most  attentively  studied,  because  of  their  very  practi- 
cal signification,  and  which  study  can  only  be  made  by  an  observer 
tion  of  many  bones.  Abscesses  of  the  roots  of  teeth  frequently  void 
themselves  into  this  cavity:  we  are  to  understand  how  and  why, 
anatomically,  such  accidents  occur.  Engorgements  of  the  cavity, 
puruloid  or  dropsical,  bulge  outward  some  part  or  other  of  the 
circumferential  walls,  perhaps  throwing  the  eye  upon  the  cheek, 
projecting  the  canine  fossee,  or  making  a  tumor  on  the  palatine 
aspect  of  the  mouth :  we  are  to  understand  why  such  bulging,  from 
a  common  cause,  is  found  so  variously  situated,  or  why,  indeed, 
such  accumulations  exist  at  all. 

If  we  make  such  a  section  of  the  superior  maxillary  bone  as  to 
expose  the  antral  cavity,  we  shall  find  that  in  many  cases,  not  in- 
deed in  all,  its  floor  is  studded  with  little  hills;  break  into  one  of 
these  elevations,  and  you  will  find  that  it  is  a  very  thin  crust,  con- 
cealing the.  root  of  some  tooth  or  teeth.  In  infrequent  cases,  a  root 
or  roots  will  be  found  projecting  into  the  cavity,  entirely  uncovered, 
save  with  the  membrane  which  had  existence  in  the  living  part.  Such 
a  view  explains  very  satisfactorily  dental  abscess  within  this  sinus. 

The  processes  which,  in  their  conjunction,  make  up  the  bone,  are 
four  in  number:  the  alveolar,  the  palatine,  the  nasal,  and  the  malar. 

The  alveolar  process,  wedged  in  between  the  malar  and  palatine, 
constitutes  perhaps  the  greatest  bulk  of  the  bone.  Looked  at  from 
below,  it  is  found  to  be  excavated  into  cavities  or  pits,  correspond- 
ing with  the  character  and  number  of  the  roots  of  the  teeth ;  these 
pits  are  termed  alveoli,  and,  in  the  recent  bone,  are  found  lined  with 
periosteal  tissue,  which  tissue  is  reflected  around  the  roots  of  the 
teeth,  forming  the  immediate  bond  of  connection.  In  some  bones, 
the  structure  making  up  this  process  is  exceedingly  loose  and  spongy; 
in  others  it  is  condensed,  and  cortical-like.  After  the  loss  of  the  teeth, 
this  process  is  removed  through  absorption ;  hence  the  approximation, 
in  old  people,  of  the  chin  and  nose.  Fractures  of  this  process,  the  re- 
sult of  falls,  blows,  or  attempts  at  tooth  extraction,  are  quite  common. 

The  tuberosity  of  the  bone  may  be  esteemed  as  the  posterior  ex- 
tremity of  the   alveolar  process,  being,  indeed,   not   unfrequently 


ANATOJIY  OF   THE  MOUTH  AND   FACE.  23 

excavated  for  the  wisdom  tooth.  This  tuljevcle,  as  implied  in  its 
name,  is  simply  a  bulb  of  bone ;  it  is  quite  vascular,  however,  and 
its  relation  to  the  posterior  tooth  subjects  it  to  sources  of  irritation, 
which  not  unfrequently  results  in  its  inflammation  and  death. 

The  malar  process,  seen  projecting  from  the  middle  of  the  bone,  is 
a  rough,  serrated  facet  for  articulation  with  the  malar  or  cheek  bone. 
This  process,  in  front,  is  seen  to  be  somewhat  concave  ;  behind  it  has 
a  similar  curvature,  and  forms  part  of  a  fossa  known  as  the  zygo- 
matic. The  chief  point  of  interest  connected  with  it,  however,  lies  in 
the  character  of  the  suture  which  unites  the  maxillary  with  the  malar 
l)one,  this  being  the  place  of  separation  in  amputation  of  the  maxillary. 

The  nasal  process,  well  represented  in  the  drawing,  but  better 
studied  and  understood  from  the  bone,  is  observed  standing  above 
the  orbital  surface.  Rising  from  the  anterior  facial  surface  of  the 
bone,  it  continues  somewhat  triangularly  upward,  until  it  ends  in  an 
irregular  semi-cell-like  extremity.  These  semi-cells  articulate  with 
the  ethmoid,  closing  in,  and  completing  the  anterior  ethmoidal  cells, 
also  with  the  frontal  bone,  completing  the  lower  boundary  of  the 
sinus  of  this  bone.  Lined  in  the  recent  state  with  the  Schneiderian 
membrane,  which  membrane  is  continued  into  the  cells  of  the  eth- 
moid and  frontal  bones,  a  moment's  reflection  recognizes  the  meaning 
of  that  sense  of  fullness  so  common  about  the  anterior  base  of  the 
cranium,  when  inflammation  and  congestion  exist  in  the  nasal  canals. 
Externally,  the  face  of  the  process  is  concave,  thus  assisting  in 
carrying  out  the  natural  curve  of  the  lateral  aspect  of  the  nose ; 
numerous  foramina  are  also  observed  on  this  face,  for  the  passage  of 
vessels.  The  tendo  oculi  has  its  attachment  on  this  surface,  while 
near,  on  the  same  plane,  is  a  line  giving  origin  to  the  levator  labii 
superior  alseque  nasi  and  orbicularis  palpebrarum  muscles.  An- 
teriorly, the  border  of  the  process  is  thin,  and  serrated  for  articula- 
tion with  the  nasal  bone.  Posteriorly,  it  is  thick,  and  hollowed 
into  a  groove  for  the  lodgment  of  the  lachrymal  sac  and  duct. 
When  in  position,  in  the  articulated  skull,  this  groove  is  converted 
into  a  canal  by  annexation  with  the  lachrymal  bone ;  the  canal, 
traced  downward,  is  found  to  have  somewhat  an  hour-glass  shape, 
being  considerably  contracted  in  the  center,  and  finally  terminating  at 
the  inferior  meatus  in  a  bell-shaped  opening.  A  little  tubercle,  the 
lachrymal,  is  seen  where  the  anterior  lip  of  the  groove  joins  the 
orbital  surface;  this  is  a  guide,  directing  the  bistoury  of  the  surgeon 
into  the  canal,  when  operations  for  its  stricture  are  demanded. 

The  orbital  surface   of  the  bone,  seen  before  in  its  articulative 


24  ORAL  DISEASES  AND  SURGERY. 

position,  is  here  observed  separate;  falling  at  direct  right  angle  from 
the  facial  aspect  of  the  bone,  it  is  observed  by  this  relation  to 
form  a  large  part  of  the  floor  of  the  orbital  cavity;  while  looked  at 
from  the  cave  of  Highmore,  it  is  seen  to  form  as  well  the  roof  of 
this  vault.  When  broken,  or  held  against  the  light,  it  is  found  to 
be  almost  a  scale  in  thinness.  The  inft-aorbital  ridge  is  simply  the 
rim  made  by  the  bending  downward  of  this  orbital  surface.  Running 
along  the  free  edge  is  observed  three  distinct  ai'ticular  faces :  the 
outer  for  the  palate  bone,  the  two  inner  for  the  orbital  or  plane  plate 
of  the  ethmoid  and  lachrymal  bones.  Below  the  rim,  or  infraorbital 
border,  is  seen  the  orbital  foramen.  Passing  a  bristle  into  this  open- 
ing, we  find  it  directed  to  the  groove  on  the  orbital  face,  the  intra- 
orbital. Passing  the  bristle  now  from  the  groove  toward  the  fora- 
men, we  find  it  may  take  some  other  track,  and  not  appear  at  the 
opening.  Searching  for  an  explanation,  we  find  the  groove,  soon 
after  entering  beneath  the  ridge,  to  divide  into  two  canals,  one  of 
which  passes  to  the  face,  as  observed,  the  other  enters  the  antrum, 
and  transmits  across  this  cavity  the  nerves  and  vessels  designed  for 
the  nutrition  of  the  anterior  teeth. 

The  osseous  boundary  of  the  nose  is  seen  in  this  drawing  to  ad- 
vantage. It  is  a  complete  curve,  and  gives  attachment  by  its  con- 
tinuous crest,  or  edge,  to  the  cartilaginous  wings. 

The  zygomatic  surface,  seen  back  of  the  malar  process,  enters  into 
the  formation  of  the  fossa  of  that  name.  It  is  to  a  degree  convex,  and 
more  or  less  rough.  Dotting  its  surface  are  observed  a  number  of 
foramina;  these  are  entrances  to  canals,  the  posterior  dental,  and 
transmit  vessels  to  the  posterior  teeth,  to  all  situated  back  of  the 
canines.  At  the  lower  part  of  this  surface,  to  the  nasal  aspect  of  the 
tuberosity,  is  a  groove  destined  to  be  converted  into  a  canal  through 
an  articulation  with  the  palate  bone,  the  posterior  dental  groove. 
This  groove  or  canal  transmits  vessels  to  the  palatine  face  of  the 
bone,  and  is  seen  to  terminate  on  the  under  side  of  the  tuberosity. 

The  muscles  of  expression,  to  Avhich  the  outer  surface  of  the  bone 
gives  origin,  are  numerous.  From  the  second  bicuspid,  back  to  the 
tuberosity,  is  a  rough  line  for  the  trumpeters,  or  buccinator  (a  similar 
line  existing  on  the  inferior  maxilla).  Above  this  first  line,  and 
below  the  malar  process,  certain  fibers  of  the  masseter  are  attached. 
Above  the  canine  fossa  is  the  origin  of  the  levator  anguli  oris ;  while 
without  this,  toward  the  concavity  of  the  nose,  is  the  line  for  the 
compressor  naris.  In  the  incisive  or  myrtiform  fossa  is  seen  the 
origin  of  the  depressor  alas  nasi. 


ANATOAIY  OF  THE  MOUTH  AND   FACE.  25 

Turning  now  toward  us  the  inner  face  of  the  bone,  we  see  the 
fourth  process,  the  palatine.  This  process  starts  out  from  the  middle 
of  the  bone,  and  divides  it  into  two  unequal  parts.  Like  the  orbital 
plate,  it  is  at  right  angles  with  the  body,  and,  when  the  piece  is 
articulated,  is  seen  to  divide  the  nose  from  the  mouth,  constituting 
the  floor  of  the  first  cavity  and  the  roof  of  the  second.  Posteriorly, 
it  is  quite  thin,  and  articulates  with  the  palatine  process  of  the  palate 
bone.  Running  forward,  it  grows  thicker  and  heavier,  and  ends  in 
the  anterior  nasal  spine.  Viewed  above,  its  surface  is  slightly  con- 
cave, to  form  the  floor  of  the  nares.  Externally,  it  becomes  merged 
into  the  body  of  the  bone;  internally  or  mesially,  it  raises  itself 
into  a  ridge,  which  is  the  one  side  of  a  groove  receiving  into  articu- 
lation the  vomer.  A  bristle  passed  through  an  opening  in  the  pro- 
cess shows  the  position  of  a  canal,  the  anterior  palatine,  transmitting 
vessels  of  that  name,  which  find  entrance  into  the  oral  cavity  through 
the  incisive  foramen  seen  just  back  of  the  center  tooth.  A  nerve,  the 
naso-palatine,  having  considerable  surgical  signification,  enters  the 
mouth  at  the  orifice  of  this  canal ;  but  is  not  transmitted  by  it, 
having  a  canal  of  its  own  in  the  intermaxillary  suture.  The  three 
marked  points  of  surgical  interest  in  this  process  are — first,  the  fact 
of  its  forming  the  boundary  between  the  mouth  and  nose,  a  break  in 
its  continuity,  and  which,  unfortunately,  is  a  not  infrequent  acci- 
dent, throwing  these  two  cavities  into  one ;  second,  the  nature  and 
relation  of  suture  with  the  palatine  process  of  palate  bone,  this  being 
the  line  of  separation  in  amputation  ;  third,  the  position  of  entrance 
of  naso-palatine  nerve,  paralj'^sis  of  the  parts  supplied  by  this  nerve 
being  a  frequent  result  of  illy  applied  pieces  of  dental  apparatus. 
To  these  three  might  be  added  a  fourth,  the  position  of  the  artery 
occupying  the  posterior  palatine  canal,  an  arter^^  which  is  sometimes 
of  considerable  size,  and  which  might  easily  be  cut  by  the  slip  of  a 
lancet  applied  to  the  gum  of  a  wisdom  tooth,  or  in  the  act  of  divid- 
ing the  tendon  of  the  flexor  palati  where  it  curves  around  the  hamular 
process. 

The  other  features  observable  on  this  aspect  of  the  bone  are  with- 
out special  surgical  interest.  Above  the  inferior  meatus,  which  is 
the  space  between  the  floor  of  the  nares  and  the  inferior  turbinated 
bone,  is  seen  the  crest  of  attachment  for  this  scroll.  Still  higher, 
on  the  nasal  process,  the  crests  for  union  with  the  superior  and 
middle  scrolls.  The  middle  meatus,  into  which  opens  the  antrum, 
is  observed  to  be  quite  a  large  space,  particularly  when  compared 
with  the  superior  meatus,  w^hich  is  the  slit  lying  between  the  upper 


26 


ORAL  DISEASES  AND  SURGERY. 


aud  middle  crests.  The  opening  of  the  antrum,  seen  in  the  back 
part  of  the  middle  meatus,  is  here  portrayed  of  a  natural  size — that 
is,  natural  to  the  disarticulated  bone.  It  will  be  remembered,  how- 
ever, that  it  is  filled  in  by  other  bones,  which,  in  the  articulated 
skull,  reduce  the  opening  to  an  outlet  not  larger  than  an  ordinary 
probe ;  the  bones  closing  in  this  cavity  are  the  ethmoid,  palate,  aud 
inferior  turbinated.    (See  descriptions  of  these  bones) 

The  superior  maxillary  bone  articulates  with  nine  others :  by  its 
nasal  crest  with  the  frontal,  ethmoid,  lachrymal,  and  nasal ;  by  its 
malar  process  with  the  malar ;  at  the  intermaxillary  suture  with  the 
opposite  maxilla;  by  its  palatine  process  with  the  palate  and  vomer, 
and  at  the  lower  of  the  lateral  crests  with  the  inferior  turbinated  bone. 

Nine  muscles  have  their  origin  from  this  bone:  orbicularis  palpe- 
brarum, inferior  oblique  of  orbit,  the  elevator  of  superior  lip  and 
wing  of  nose,  the  proper  elevator  of  lip,  the  angular  elevator,  com- 
pressor naris,  depressor  of  ala,  masseter,  and  buccinator. 

INFEKIOR  MAXILLAEY  BONE. 

The  inferior  maxillary  bone,  the  largest  and  strongest  bone  of  the 
face,  consists  of  a  body,  horseshoe  in  shape,  and  two  rami,  joined 
to  the  body  at  right  angles.  The  body,  which  is  the  anterior 
portion,  is  surmounted  by  a  process  of  more  or  less  spongy  bone, 
excavated  for  the  reception  of  the  teeth  ;  the  basement  portion,  or 

Fio.  4. — Inferior  Maxillary  Boxe. 


1,  body;  2,  ramus;  3,  symphysis;  4,  base ;  5,  angle;  6,  mental  foramen;  7,  condyle;  8, 
coronoid  process ;  9,  semihmar  notch ;  10,  inferior  dental  foramen,  the  entrance  of  the 
corresponding  canal;  11,  alveolar  border;  12,  incisor  teeth;  13,  canine  tooth;  14,  premo- 
lars; 15,  large  molars. 


that  portion  beneath  the  spongy  series  of  cells,  or  alveolar  process, 
is  made  up  of  very  dense  structure,  and  so  hard  and  resisting  as  to 
be  able  to  withstand  veiy  considerable  blows.       The  rami,  curved 


ANAT03IY  OF  THE  MOUTH  AND   FACE.  27 

and  angular  at  the  base,  terminate  above  in  two  processes :  the 
condyloid,  for  articulation  with  the  glenoid  cavity  in  the  temporal 
bone,  and  the  coronoid,  for  the  attachment  of  the  temporal  muscle. 
The  angle  of  relation  of  the  perpendicular  to  the  horizontal  portion 
of  the  bone  varies  with  different  ages.  In  early  infancy  it  is  very 
obtuse ;  indeed,  the  two  portions  are  nearly  on  the  same  plane.  In 
adult  life  a  right-angled  relation  is  obtained,  and  this  changes  again 
to  the  obtuse  as  age  advances,  and  the  teeth  fall  out.  Taking 
advantage  of  a  knowledge  of  these  changes,  the  surgeon  is  enabled 
to  correct,  in  young  life,  the  great  deformity  of  an  unduly  project- 
ing lower  jaw.J 

Looking  at  the  external  face  of  the  body,  the  attention  is  first 
attracted  by  a  prominent  foramen  situated  beneath  the  bicuspid 
teeth.  This  foramen  is  called  the  mental,  and  from  it  passes  out, 
to  be  distributed  to  the  lip  and  gum,  the  inferior  dental  artery  and 
nerve ;  the  situation  of  the  foramen  represents  the  line  of  relation 
between  the  hard  and  spongy  portions.  It  is  at  this  opening  that 
section  of  the  nerve  is  occasionally  made  for  severe  and  resisting 
mental  neuralgia.  A  bristle  passed  into  this  foramen,  looking  back- 
ward, is  directed  along  a  canal  at  the  base  of  the  teeth,  and  emerges  at 
an  opening  situated  on  the  inner  face  of  the  ramus.  Passed  forward, 
it  enters  a  smaller  canal,  which  continues  under  the  central  teeth, 
carrying  to  these  organs  branches  of  the  nerve  and  artery.  An 
oblique  line — the  external  oblique  line,  as  it  is  called — fairly  divides 
the  surface  of  the  body  into  two  triangles.  This  line  is  for  the  at- 
tachment of  muscles,  and  accommodates  the  buccinator,  in  part, 
the  depressor  anguli  oris,  and  the  depressor  labii  inferioris.  In  old 
persons,  after  the  loss  of  the  teeth,  and  absorption  of  the  alveolar 
process,  it  is  found  to  run  almost  along  the  upper  surface.  The 
center  line,  called  the  symphysis,  represents  the  position  or  di- 
vision existing  in  the  young  bone,  union  of  the  two  halves  not 
occurring  until  about  the  end  of  the  first  year.  The  levator  menti 
muscle  has  its  origin  from  the  fossa  at  the  side  of  this  line.  The 
mental  process,  the  tubercle  at  the  base  of  the  symphysis,  is  only  a 
thickening  or  an  hypertrophy,  for  the  greater  strength  of  the  part. 
Viewed  from  above  downward,  the  body  of  the  lower  jaw  is  con- 
cave ;  from  behind  forward  it  is  convex. 

The  external  face  of  the  ramus  or  perpendicular  portion  of  the 
bone  exhibits  a  quadrilateral  aspect,  broken  above  by  a  notch,  the 
sigmoid,  which  separates  the  two  projecting  processes.  The  an- 
terior of  these  processes  is  a  thin,  flattened,  triangular  eminence, 


28  ORAL  DISEASES  A.VD  SURGERY. 

giving  attachment  to  the  masseter  and  temporal  muscles.  The  pos- 
terior eminence,  the  condyloid  process,  is  an  oval  projection,  convex 
and  smooth,  with  its  face  covered  with  articular  cartilage,  and 
having  its  greatest  width  from  side  to  side.  The  process  articulates 
the  bone  with  the  occipital,  and  is  occasionally  the  seat  of  fracture 
and  luxation. 

The  internal  face  of  the  bone  presents  the  same  general  view 
with  the  external. 

A  ridge,  the  mylo-hyoid,  divides  the  body  by  its  oblique  line 
into  two  parts.  To  this  ridge  is  attached,  or  rather  from  it  has 
origin,  a  muscle  of  the  same  name.  This  muscle,  with  its  fellow  of 
the  opposite  side,  forms  the  floor  of  the  mouth,  so  that  looking  at  the 
line  one  sees  exactly  how  much  of  the  bone  is  within  and  how  much 
without  the  oral  cavity.  Just  below  the  line,  about  midway  of  the 
body  of  the  bone,  is  seen  a  fossa  or  depression,  the  submaxillary,  for 
the  accommodation  of  the  gland  of  that  name.  The  mesial  line  or 
symphysis  presents  on  either  side  two  tubercles,  called  the  genial 
tubercles,  to  which  are  attached  the  genio-hyoglossi  and  the  genio- 
hyoideus  muscles.  Outside  of  these  tubercles,  on  either  side,  are  two 
fossae  for  the  lodgment  of  the  sublingual  glands ;  these  fossag  are 
called  after  the  name  of  the  glands.  It  will  be  observed  that  these 
fossae  lying  above  the  ridge,  the  lingual  glands  must  be  within  the 
mouth,  while  the  submaxillary  fossa  being  below  it,  these  glands 
are  without  the  cavity.  One  most  important  feature  to  remark  is 
the  relation  of  the  anterior  border  of  the  vertical  portion  of  the  bone 
to  the  molar  teeth.  It  not  unfrequently  happens  that  the  border  so 
nearly  approaches  the  second  molar  that  there  is  no  room  left  for  the 
eruption  of  the  third;  the  most  formidable  inflammations  sometimes 
result  from  such  a  cause,  the  crown  of  the  tooth  being  held  down 
under  the  ramus.  Extraction  of  the  adjoining  anterior  tooth,  it  will 
be  seen,  would  allow  the  confined  one  to  fall  forward. 

A  marked  feature  of  difference  between  the  internal  and  external 
face  of  the  ramus  is  the  existence  in  the  former  of  a  large  foramen, 
the  inferior  dental,  for  transmission  into  the  canal  alluded  to,  as 
passing  beneath  the  teeth,  of  the  inferior  maxillary  vessels  and  nerve. 
The  position  of  this  foramen  is  to  be  appreciated  by  accurate  meas- 
urement, as  just  within  it  is  performed  the  operation  of  section  of  the 
nerve.  A  groove,  the  mylo-hyoid,  transmits  to  the  muscles  of  the 
ridge  an  arter}^,  which  comes  from  the  inferior  maxillary  just  as  it 
is  about  to  enter  its  canal.  Attached  to  the  border  and  internal  face 
of  the  coronoid  process  is  the  tendinous  expansion  of  the  temporal 


ANATOMF  OF   THE  MOUTH  AND   FACE. 


29 


muscle,  while  to  the  face  of  the  condyloid  is  attached  the  pterygoideus 

externus,  the  internal  pterygoid  being  attached  to  the  angle.     The 

semilunar   depression,  separating   the   two  condyles,  the  sigmoid 

notch,  is  crossed  by  the  masseteric  artery  and  nerve,  while  in  its 

immediate  proximity  is  the  internal  carotid  and  internal  maxillary 

arteries. 

Figs.  5  and  6. — Palate  Bone. 


Posterior  view  of  the  right  palate  bone. 
1,  palate  plate ;  2,  nasal  plate ;  3,  pyramidal 
process ;  4,  articular  border  for  the  left  i)alate 
bone;  5,  palate  spine;  6,  ridge  for  junction 
with  the  turbinated  bone  ;  7,  spheno-palatine 
notch,  between  8,  the  orbital,  and  9,  the 
sphenoidal  process ;  10,  groove  for  the  in- 
ternal pterygoid  process  of  the  sphenoid 
bone;  11,  position  of  the  posterior  palatine 
foramen. 


Exterior  view  of  the  right  palate  bone. 
1,  rough  surface  articulating  with  the  su- 
perior maxillary  bone,  and  diminishing  the 
aperture  of  the  maxillary  sinus;  2,  posterior 
palatine  canal,  completed  by  the  tuberosity 
of  the  superior  maxillary  bone ;  3,  spheno- 
palatine notch;  4,  5,  6,  orbital  process;  4, 
surface  directed  toward  the  pterygo-max- 
illary  fossa;  5,  orbital  surface;  6,  maxillary 
border;  7,  sphenoidal  process;  8,  pj'ramidal 
process. 


The  palate  bone  in  position  is  seen  to  form  the  back  part  of  the 
hard  palate,  a  portion  of  the  floor  and  side  of  the  nares,  and  a  part 
of  the  orbital  cavity.  It  also  enters  into  the  formation  of  three 
fospae:  the  zygomatic,  spheno-maxillary,  and  pterygoid.  Like  the 
inferior  maxillary,  the  bone  consists  of  two  portions:  one  horizontal, 
the  other  at  right  angles  with  it,  or  vertical.  The  horizontal  portion 
is  irregularly  quadrilateral,  presenting  two  surfaces  and  four  borders  : 
the  upper  of  the  two  surfaces  is  concave,  and  forms  the  back  part  of 
the  floor  of  the  nares ;  the  lower  or  under  surface  is  also  concave,  and 
forms  the  back  of  the  hard  palate.  The  suture  of  connection  Avith 
the  maxillary  bone  is  always  plainly  seen,  and  is  called  the  palato- 
maxillary suture. 

In  glancing  at  the  bone  from  its  posterior  view,  it  is  seen  veiy 
markedly  to  resemble  the  letter  L.  Studying  it  in  detail,  we  may 
remark,  first,  the  spine,  situated  at  the  base  of  the  interpalatal 
suture,  and  which  gives  attachment  to  the  motores  uvu]89  muscles  ; 
passing  toward  the  vertical  portion,  the  concave  character  of  both 


30  ORAL  DISEASES  AXD  SURGERY. 

nasal  and  palatine  faces  is  observed,  the  former  much  more  marked 
than  the  latter.  This  nasal  concavity  is  seen  to  end  at  a  crest  or 
ridge  on  the  vertical  portion.  This  ridge  is  the  most  posterior  articular 
surface  of  the  inferior  turbinated  bone,  and  the  space  below  it  a  part 
of  the  inferior  meatus.  The  base  of  the  vertical  portion  is  pyramidal, 
and  ends  in  a  process  called  the  pterygoid  or  tuberosity,  its  articu- 
lation being  with  the  pterygoid  plates  of  the  sphenoid.  At  the 
back  part  of  this  process  ai'e  seen  the  three  grooves :  the  middle 
one,  wide  and  smooth,  forms  part  of  the  pterygoid  fossa,  and  gives 
attachment  to  the  internal  pterygoid  muscle ;  the  two  lateral  are 
rough  and  uneven,  and  articulate  with  the  anterior  border  of  each 
pterygoid  plate. 

Passing  upward,  the  prominent  feature  is  the  sphenoid  process. 
This  is  a  comparatively  thin  plate,  made  up  of  an  articular  and  non- 
articular  surface,  a  groove  and  a  notch.  The  articular  surface  as- 
sociates the  plate  with  the  sphenoid  bone ;  the  non-articular  enters  into 
the  composition  of  the  zygomatic  fossa.  The  groove  contributes  to 
the  formation  of  the  pterygo-palatine  canal ;  and  the  notch,  closed 
in  above  by  the  orbital  process,  forms  the  greater  part  of  the 
spheno-palatine  foramen.  This  process  also  contributes,  by  one  of 
its  surfaces,  to  the  lateral  wall  of  the  nasal  fossa. 

The  orbital  process,  resting  on  the  sphenoidal,  is  composed  of 
five  plates,  or  surfaces,  inclosing  a  cavity.  Of  these  processes,  three 
are  articular,  two  free  surfaces.  The  articular  are  the  maxillary, 
the  sphenoidal,  and  the  ethmoidal,  associating  the  process  with  these 
bones.  The  free  surfaces  are  the  orbital,  forming  a  small  part  of  the 
orbital  cavity,  and  the  zygomatic  surface  entering  into  the  composi- 
tion of  this  fossa. 

Looking  on  the  inner  face  of  the  bone,  we  remark,  first,  the  articu- 
lar process.  This  process  or  surface  associates  the  bone  with  its 
fellow  of  the  opposite  side;  above,  it  forms,  with  its  neighboring 
piece,  a  ridge  receiving  the  vomer.  The  body  of  this  face  seems 
made  up  of  two  great  concavities,  with  a  separating  ridge.  This 
ridge  articulates  the  inferior  turbinated  bone ;  the  concavity  above 
is  part  of  the  middle  meatus ;  that  below,  part  of  the  inferior 
meatus ;  the  ridge  or  crest  is  called  the  inferior  turbinated  crest. 
A  second  crest,  situated  at  the  upper  boundary  of  the  middle  meatus, 
articulates  the  lower  scroll  of  the  ethmoid,  or  the  middle  turbinated 
bone.  This  is  called  the  superior  turbinated  crest.  Just  below  it  is 
seen  the  now  perfected  notch  in  the  sphenoidal  process,  the  spheno- 
palatine foramen,  for  the  transmission  of  the  vessels  and  nerve  of 


AXATOMY  OF  THE  MOUTH  AND   FACE.  31 

that  name.  Above  the  superior  crest  is  seen  the  posterior  part  of 
the  superior  meatus,  a  horizontal  groove,  bounded  above  by  the 
lower  border  of  the  ethmoidal  face  of  the  orbital  process. 

The  orbital  process,  seen  from  this  side,  presents  three  surfaces: 
the  maxillary  in  front,  the  orbital  above,  and  the  ethmoidal  in- 
ternally. 

The  lateral  surfaces  of  the  bone  are  almost  entirely  articular. 
That  looking  front  associates  in  its  full  length  with  the  superior 
maxillary  bone ;  that  looking  back,  with  the  sphenoid,  through  its 
pterygoid  processes.  This  very  full  articulation  with  these  two  bones 
leads  us  to  speak  of  the  palate  bone  as  being  wedged  between  them, 
and  being  supported  by  them. 

The  articulations  of  the  palate  bone  are  with  seven  others:  the 
superior  maxillary,  the  inferior  and  superior  turbinated,  the  vomer, 
the  sphenoid,  the  ethmoid,  and  its  fellow  of  the  opposite  side. 

The  muscles  attached  to  it  are  the  tensor  palati,  the  motor  uvula, 
the  internal  and  external  pterygoid. 

THE  VOMEE. 

The  vomer,  plowshare-shaped,  constitutes  a  portion  of  the  sep- 
tum narum.  It  articulates  below  with  the  interpalatine  suture  of 
the  superior  maxillae  and  palate  bones;  above,  with  the  perpen- 
dicular plate  of  the  ethmoid ;  by  its  base  with  the  laminae  and  ros- 

FiG.  7. — The  Vomer. 


View  of  left  side.  1,  1,  broad  groove  receiving  the  rostrum  of  the  sphenoid  bone; 
2,  2,  inferior  border  articulating  with  the  palate  plates  of  the  superior  maxillary  and 
palate  bones ;  3,  posterior  border,  the  dividing  line  of  the  posterior  nares  ;  4,  4,  groove 
border  receiving  a  narrow  slip  of  cartilage,  situated  between  the  vomer  and  the  nasal 
plate  of  the  ethmoid  bone ;  5,  5,  border  for  the  cartilaginous  septum  of  the  nose ;  6,  6, 
nasal  surface. 

trum  of  the  sphenoid  bone ;  in  front  it  associates  with  the  triangular 
cartilage;  posteriorly  it  is  seen  separating  the  nares.  The  naso- 
palatine groove,  seen  running  from  the  base,  forward  and  downward, 
toward  the  triangular  cartilage,  transmits  the  naso-palatine  nerve  to 
the  interpalatine  canal. 


32  ORAL  DISEASES  AND  SURGERY. 

Occasionally  it  is  the  case  that  the  vomer  is  found  markedly  bent 
to  one  side  or  the  other,  and  this  to  such  an  extent,  frequently,  as  to 
completely  obliterate  one  of  the  nares,  requiring  an  operation  for  its 
relief.  The  vomer  is  also  subject  to  syphilitic  attacks,  and  frequently 
breaks  down,  allowing  the  arch  of  the  nose  to  fall  in. 

Fig.  8. — Articular  Kelations  of  Vomer. 

J 


Vertical  section  of  the  face,  exhibiting  the  osseous  nasal  septum.  1,  frontal  bone; 
2,  frontal  sinus ;  3,  nasal  spine  of  the  frontal  bone ;  4,  nasal  bone ;  5,  nasal  spine  of  the 
superior  maxillary  bone ;  6,  nasal  process  of  the  same  bone ;  7,  border  of  the  palate  plate 
of  the  same ;  8,  incisive  foramen ;  9,  left  posterior  naris ;  10,  palate  plate  of  the  palate 
bone ;  11,  nasal  plate  of  the  ethmoid  bone ;  12,  ethmoidal  crest ;  13,  vomer ;  14,  left  turbi- 
nated bone  ;  15,  sphenoidal  sinus  ;  16,  internal  pterygoid  process  ;  17,  external  pterygoid 
process. 

The  articulation  is  seen  to  be  with  six  bones :  the  two  superior 
maxillary,  two  palate,  the  sphenoid,  and  ethmoid ;  also  with  the 
cartilaginous  septum,  not  shown  in  the  view,  but  occupying  the 
triangular  break. 

Running  across  each  lateral  face  of  the  nasal  cavities  are  three 
scrolls,  known  as  the  turbinated  bones.  Of  these  scrolls,  the  two 
upper  are  simply  processes,  or  portions  of  the  ethmoid  bone ;  the 
lower  is  a  distinct  piece,  and  is  called  the  inferior  turbinated  bone. 

Observing  the  position  of  these  scrolls,  it  is  remarked  that  each 
curves  over  a  portion  of  the  sides  of  the  nares.  The  spaces  thus  in- 
closed are  called  the  meatuses.  The  lower  or  inferior  of  these  cavities 
is  bounded  below  by  the  floor  of  the  nares ;  above  by  the  inferior 
turbinated  bone.     An  opening  seen  about  its  middle  is  the  outlet  of 


ANATOMT  OF  THE  MOUTH  AND   FACE.  33 

the  lachrymal  canal.  The  middle  meatus  is  the  space  bounded  below 
by  the  upper  surface  of  the  inferior  scroll ;  above  by  the  lower  sur- 
face of  the  middle  scroll.  A  foramen  seen  in  this  meatus  is  the  outlet 


Fig.  9. — Position  and  Eelations  of  Turbinated  Bones. 


View  of  the  outer  wall  of  the  right  nasal  ross.i.  1,  frontal  bone ;  2,  its  orbital  plate ; 
3,  its  nasal  spine;  4,  nasal  bone;  5,  ethmoid  bone;  6,  its  upper  turbinated  process;  7,  its 
lower  turbinated  process ;  8,  turbinated  bone ;  9,  process  of  the  lachrymal  bone,  within 
the  position  of  which  is  the  lachrymo-nasal  duct ;  10,  nasal  spine  of  the  superior  maxillary 
bono  ;  11,  naso-palatine  canal;  12,  palate  plate  of  the  superior  maxillary  bone;  13,  nasal 
process  of  the  latter ;  14,  external  pterygoid  process ;  15,  internal  pterygoid  process ;  16, 
nasal  plate  of  the  palate  bone ;  17,  its  palate  plate ;  18,  posterior  palatine  foi-amen ;  19, 
superior  meatus  of  the  nose;  20,  middle  meatus;  21,  inferior  meatus;  22,  fi-ontal  sinus; 
23,  sphenoidal  sinus ;  24,  its  communication  with  the  upper  back  part  of  the  nose ;  25, 
spheno-palatine  foramen;  26,  orifice  of  the  maxillary  sinus. 

of  the  antrum.    The  superior  meatus  is  the  slit  seen  between  the  two 
upper  scrolls. 

The  distinct  or  inferior  turbinated  bone  is  a  thin,  spongy  scroll, 
having  a  base  of  attachment  the  whole  length  of  the  lower  crest 
seen  on  the  nasal  surfaces  of  the  maxillary  and  palate  bones ;  the 
opposite  or  inferior  edge  is  free,  and  lies  in  the  middle  of  the  in- 
ferior meatus.  Yiewed  from  its  inner  surface,  the  bone  presents  a 
most  irregular  appearance,  being  perforated  with  numerous  aper- 
tures, sulci,  and  grooves,  for  the  accommodation  of  arteries  and 
veins.  Two  processes,  the  lachrymal  and  ethmoid,  are  seen  to  break 
the  regularity  of  the  upper  convexity.  The  anterior,  the  lachrymal, 
articulates  with  the  inferior  angle  of  the  lachrymal  bone,  and  with 
the  nasal  crest  of  the  maxillary  bone,  thus  assisting  in  forming  the 

3 


34 


ORAL  DISEASES  AND  SURGERY. 


lachrymal  canal.  The  posterior,  the  ethmoidal,  articulates  with  the 
descending  unciform  process  of  the  ethmoid  bone.  Turning  here  the 
bone,  we  see  a  third  process,  or  division,  as  it  were,  made  in  the 
ethmoidal.  This  process  is  called  the  maxillary.  It  curves  down- 
ward within  the  inferior  meatus,  assisting  in  filling  up  the  antral 
orifice,  and,  in  its  attachment,  steadies  the  bone  firmly  on  the  side 
of  the  nares.  Externally,  the  general  appearance  of  the  bone  is  con- 
cave ;  internally,  or  looking  toward  the  septum  narum,  it  is  convex. 
If  the  external  surface  was  convex,  and  the  processes  absent,  the  bone 
might  very  well  be  likened  in  shape  to  the  Indian  stone  arrow-head. 

The  turbinated  bone  is  very  subject  to  specific  inflammation,  and 
which,  without  great  care,  is  apt  to  end  in  its  death. 

The  bone  articulates  with  four  others:  the  ethmoid,  the  lachry- 
mal, the  maxillary,  and  palate.     No  muscles  are  attached  to  it. 

THE  ETHMOID  BONE. 


Fig.  10. 


-Ethmoid  Boxe — Gexekal 
View. 


A  horizontal  cribriform  plate  of  bone,  with  a  crest  along  its  middle  ; 
a  perpendicular  plate  dropping  down  from  the  center  of  this  first 

piece ;  two  little  oblong  square 
boxes,  hung  on  either  side  of  the 
perpendicular  plate,  leaving  the 
space  of  a  narrow  slit  between 
the  boxes  on  either  side  and  the 
plate,  and  we  have  the  complete 
idea  of  the  ethmoid  bone.  Look- 
ing at  the  bone  from  above,  we  re- 
mark, first,  the  crest — crista  galli 
it  is  called — giving  attachment  to 
the  falx  cerebri.  On  either  side 
of  this  crest  is  seen  a  depression 
perforated  with  a  number  of  fora- 
mina. These  depressions  lodge 
the  olfactory  bulbs,  and  the  fora- 
mina transmit  to  the  nose  the 
olfactory  filaments,  the  three  sets 
having  corresponding  foramina. 
A  slit  seen  at  the  side  of  the 
crista  galli  transmits  the  nasal 
branch  of  the  ophthalmic  nerve, 
the  crest  is  seen  to  tei'minate  in  two  little 


1,  orbital  surface  of  the  lateral  mass;  2, 
posterior  extremity  of  the  crihriform  plate, 
which  unites  the  lateral  masses,  and  is  de- 
pressed and  perforated  with  numerous  fora- 
mina on  each  side  of  the  ethmoidal  crest  3 ; 
the  two  oblique  processes  in  advance  of  the 
latter  are  the  ethmoidal  wings;  4,  anterior 
extremity  of  the  nasal  plate ;  5,  the  ethmoidal 
sinuses. 


Looked  at  anteriorlv. 


ANATOMY  OF  THE  MOUTH  AND   FACE.  35 

horns  or  wings ;  these  articulate  with  depressions  in  the  os  frontis, 
and  occasionally  in  a  manner  so  imperfect  as  to  leave  an  opening 
or  foramen.  When  existing,  this  foramen  accommodates  a  nasal 
vein,  which  passes  upward,  to  terminate  in  the  longitudinal  sinus  ; 
the  rupture  of  this  vein,  discharging  the  sinus,  has  saved  many 
lives  in  attacks  of  congestion. 

The  perpendicular  plate,  exhibited  by  the  removal  of  one  of  the 
lateral  masses,  is  simply  a  thin  plate  of  bone.  This,  descending  in 
the  middle  line  of  the  nose,  assists  the  vomer  in  separating  this 
cavity  into  two  lateral  halves.  In  front,  it  is  received  into  the 
groove  between  the  two  nasal  bones ;  below,  it  looks  downward  and 
forward,  and  receives  the  triangular  cartilage ;  back  of  this  it  articu- 
lates with  the  vomer,  and  still  farther  back  with  the  sphenoid. 

On  each  side  of  the  plate  are  seen  numerou^s  grooves  leading  from 
the  foramina  in  the  horizontal  or  cribriform  plate ;  these  are  chan- 
nels receiving  and  shielding  the  inner  olfactory  filaments. 

The  boxes  or  lateral  masses  are  very  loose,  and  areolar-like,  and 
constitute  a  series  of  cells.  Disarticulated,  many  of  these  cells 
appear  broken ;  but  when  associated  with  the  ethmoidal  fissure  of  the 
frontal  bone,  with  the  sphenoidal  scrolls,  with  the  orbital  processes 
of  the  palate  bones,  and  the  nasal  processes  of  the  maxillary  and 
palate  bones,  the  cells  are  found  to  be  completed.  The  union  of 
these  cells,  more  or  less  directly,  with  the  common  nares,  and  the 
fact  that  they  are  all  lined  by  a  mucous  membrane  continued  from 
these  fossae,  explain  the  sense  of  congestion  and  fullness  known  as 
"  cold  in  the  head." 

The  outer  surface,  or  face  of  the  boxes,  looks  very  much  in  color 
like  the  common  clarified  quill,  is  semi-translucent,  very  square,  and 
very  smooth.  In  referring  to  the  view  of  the  skull  (Fig.  1),  this 
surface  will  be  seen  entering  into  the  composition  of  the  orbital 
cavity. 

The  portion  of  the  ethmoid  which  receives  and  articulates  the 
process  passing  upward  from  the  inferior  turbinated  bone  is  a 
hook-like  projection  from  the  under  surface  of  these  lateral  masses. 
It  is  called  the  unciform  process,  and  assists  in  narrowing  the  orifice 
of  the  antrum  and  supporting  the  masses. 

The  internal  surface  of  each  lateral  mass  approaches  the  perpen- 
dicular plate.  At  the  upper  part  is  the  narrow  fissure,  bounded  by 
a  scroll-like  process  on  the  surface,  known  as  the  superior  meatus. 
The  scroll  has  received  the  name  of  the  superior  turbinated  bone. 
Below  this  first  scroll,  on  the  same  surface,  is  a  second.   This  second 


36 


ORAL  DISEASES  AND   SURGERY. 


scroll  is  called  the  middle  turbinated  bone,  and  the  space  below  it, 
between  it  and  the  inferior  turbinated  bone,  is  the  middle  meatus. 

In  looking  at  the  ethmoid  bone  in  position,  it  will  be  seen  to  be 
Avedged  in  between  the  nasal,  frontal,  lachrymal,  and  maxillary 
bones  in  front,  and  the  sphenoid  behind;  below,  it  is  supported  by 
the  turbinated,  vomer,  and  palate  bones.  Blows  received  upon  the 
bridge  of  the  nose  have  not  unfrequently  carried  the  crista  galli 
into  the  substance  of  the  brain  ;  while  maxillary  diseases  find  an 
easy  road  to  the  base  of  the  cranium  through  the  nasal  communica- 
tion with  the  ethmoidal  cells. 

THE  SPHENOID  BONE. 

The  sphenoid  bone,  named  from  its  wedge-like  relations  to  other 
bones  of  the  cranium,  has  been  frequently  and  most  aptly  compared 
in  appearance  to  a  "bat"  with  extended  wings  and  unflexed  legs. 


Fig.  11. — The  Sphenoid  Bone — XJppek  Vieav. 


1,  pituitaiy  fossa;  2,  olivary  process ;  3,  declivity;  4,  anterior  cliiioid  process;  5,  pos- 
terior clinoid  process;  6,  posterior  border  of  the  body;  7,  cerebral  surface  of  the  great 
wing ;  8,  articular  sui-face  for  the  frontal  bone  ;  9,  articular  border  for  the  temporal  bone  ; 
10,  spinous  process ;  11,  small  wing;  12,  border  articulating  with  the  orbital  plate  of  the 
frontal  bone;  13,  border  joining  the  ethmoid  bone;  14,  optic  foramen;  15,  sphenoidal  for- 
amen ;  16,  rotund  foramen  ;  17,  oval  foramen  ;  18,  spinous  foramen ;  19,  groove  for  the  in- 
ternal carotid  artery. 

In  looking  at  the  disarticulated  bone,  we  first  observe  a  central 
portion  or  body ;  this  body  is  irregularly  square,  and  marked  on  all 
its  surfaces  with  features  which  one  at  once  infers  to  be  possessed 
of  anatomical  significance.  Extending  laterally  on  either  side  from 
the  body  are  two  great  wings;  these  wings  are  made  double  by 
a  lacerated  foramen,  and  instead  of  being  spoken  of  and  described 
as  a  single  pair,  are  mostly  viewed  as  two  pairs — the  larger  portion 
being  called  the  greater  wings,  the  smaller  pair  the  lesser  wings. 


ANAT03IF  OF  THE  MOUTH  AND   FACE. 


37 


The  Icg-s,  falling  from  the  base  of  the  cranium,  are  found  separated 
by  a  notch  into  two  portions, — this  separation,  however,  being  much 
more  marked  behind  than  in  front:  they  have  received  the  name  of 
pterygoid  processes. 

Fig.  12. — The  Sphenoid  Bone — Front  View. 


1,  2,  sphenoidal  crest  and  rostrum  for  joining  the  nasal  plate  of  the  ethmoid  bone  and 
the  vomer  ;  3,  entrance  of  the  sphenoidal  sinuses ;  4,  small  wing ;  5,  optic  foramen  piercing 
its  base  ;  6,  sphenoidal  foramen  ;  7,  rotund  foramen  ;  8,  orbital  surface  of  the  great  wing ; 
9,  temporal  surface  of  the  same ;  10,  ridge  separating  the  temporal  and  spheno-maxillary 
fos8!B  ;  11,  position  of  the  pterygo-palatiue  canal ;  12,  pterygoid  canal ;  13,  internal  ptery- 
goid process,  ending  in  a  hook  14;  15,  external  pterygoid  process ;  16,  spinous  process  ; 
17,  oval  foramen ;  18,  spinous  foramen. 


Beginning  a  study  of  the  body  from  its  superior  or  cranial  surface, 
a  first  attention  is  naturally  directed  to  a  saddle-like  depression 
occupying  a  large  portion  of  this  face.  This  depression  lodges  a 
little  body  attached  to  the  floor  of  the  third  ventricle,  called  the 
pituitary  body;  hence  is  called  by  many  authors  the  pituitary  de- 
pression or  fossa:  from  its  resemblance  to  the  Turkish  saddle  it 
is  as  frequently  named  the  sella  turcica.  A  number  of  little  pits 
seen  on  the  floor  are  foramina  transmitting  to  the  body  vessels  of 
nutrition.  On  either  side  are  two  processes ;  these  correspond  to 
two  others,  terminating  the  plate  of  bone  which  represents  the 
back  of  the  saddle.  The  four  have  been  compared  to  the  posts  of 
a  bedstead,  and  called  clinoid  processes.  Passing  forward,  an  olive- 
shaped  eminence  is  next  noticed — the  olivary  process ;  and  directly 
in  front  of  this,  a  groove  or  oblong  fossa.  This  groove  has  rest- 
ing in  it  the  commissure  of  the. optic  nerve;  hence  called  the  optic 
groove.  Passing  directly  forward,  we  find  the  surface  terminate 
in  a  spine  or  projecting  point;  this  point  articulates  the  surface 
with  the  ethmoidal  bone,  and  is  called  the  ethmoidal  spine ;  be- 
tween this  spine  and  the  optic  groove  is  a  slight  eminence  falling 
off"  on  either  side  into  a  line  of  depression ;  these  lines  lodge  the 


38  ORAL  DISEASES  AND  SURGERY. 

olfactory  nerves.  Two  foramina,  seen  on  this  surface  at  either  ter- 
minus of  the  optic  groove,  are  called  optic  foramina;  they  transmit 
to  the  orbital  cavities  the  optic  nerves  and  ophthalmic  arteries. 
From  the  back  of  the  saddle  the  surface  is  seen  to  slope  gradually 
downward;  this  concave  plane  lodges  the  medulla  oblongata,  and 
terminates  at  the  line  of  union  with  the  occipital  bone.  On  either 
side  is  situated  a  tortuous  depression,  in  which  lies  the  internal 
carotid  arteries  and  cavernous  sinuses. 

Turning  now  to  the  anterior  surface,  we  observe,  first,  a  rostrum 
or  beak,  for  articulation  with  the  perpendicular  plate  of  the  ethmoid. 
On  either  side  of  this  beak  are  seen  scrolls  of  bone,  or  rather  la- 
mellae,— the  sphenoidal  turbinated  bones,  as  they  are  called.  These 
lamellae  w^e  find  imperfectly  close  sinuses  which  hollow  out  the  sub- 
stance of  the  body,  and  which,  in  articulation,  are  found  to  com- 
municate with  the  upper  part  of  the  nose,  and  frequently  with  the 
ethfnoidal  cells  ;  being  lined  with  the  mucous  membrane  of  the 
nares,  and  subjected  consequently  to  the  sympathies  of  continuity. 

The  inferior  surface  presents  us,  first,  with  this  rostrum  or  beak ; 
continued  from  the  anterior  face,  this  spine  is  received  into  a  groove 
or  fissure  in  the  vomer.  On  either  side  are  laminae  of  bone,  which  pass 
to  the  pterygoid  processes ;  these  plates  or  laminae  are  called  vaginal 
jjrocesses.  Close  to  the  pterygoid  process  is  seen  a  groove,  which  the 
sphenoidal  process  of  the  palate-bone  converts  into  a  canal ;  this 
groove  transmits  the  pterygo-palatine  vessels  and  pharyngeal  nerve. 

The  posterior  surface  in  most  bones  exhibits  simply  a  quadri- 
lateral sawed  surface,  a  union  existing  with  the  occipital  at  this  point, 
which  has  required  the  saw  for  its  separation.  Hence  it  has  been 
a  common  practice  with  many  writers  to  consider  the  sphenoid  and 
occipital  as  one  bone,  and  to  refer  to  them  as  the  spheno-occipital  bone. 

The  wings,  which  may  next  claim  attention,  are  called  the  greater 
and  lesser,  the  separation  existing  at  the  lacerated  foramen.  The 
greater  wings  extend  laterally,  and  assist  largely  in  forming  the 
floor  of  the  fossae  which  receive  the  middle  lobes  of  the  brain. 
Looked  at  from  the  encranial  aspect,  attention  is  first  attracted  to 
six  foramina — three  on  either  side.  The  first  of  these  is  a  round 
hole,  and  is  called  the  foramen  rotundum ;  it  transmits  from  the 
brain  to  the  superior  maxillary  bone  the  second  branch  of  the  fifth 
nerve.  The  second  hole  is  oval  in  shape ;  hence  called  the  foramen 
ovale  :  it  transmits  the  third,  or  inferior  maxillary  branch  of  the  fifth. 
The  third,  the  foramen  spinosum,  transmits  the  middle  meningeal 
artery.     A  fourth  foramen  is  occasionally  found  in  the  great  wing — 


ANA  TOM F  OF   THE  MOUTH  AND   FACE.  39 

the  vesalii.  When  existing,  it  is  occupied  by  a  small  vein.  The 
,u<neral  floor  of  these  wings  is  concave,  and  marked  with  elevations 
and  depressions  for  the  accommodation  of  neighboring  convolutions. 

Turning  the  bone,  these  wings  are  seen  to  be  made  up  of  three 
surfaces:  the  encranial  face,  as  just  described;  an  external  surface, 
nccupying,  when  in  articulation,  a  place  in  the  base  of  the  skull;  and 
an  orbital  surface. 

The  external  surface  is  irregularly  convex,  and  is  separated  into 
two  portions  by  a  ridge  called  the  pterygoid.  The  superior  of  these 
two  faces  is  seen  entering  into  the  composition  of  the  temporal  fossa 
for  lodgment  of  temporal  muscle.  The  inferior  face  lies  beneath  the 
zygoma,  and  forms  part  of  the  fossa  of  this  name,  giving  attachment 
to  the  external  pterygoid  muscle.  Running  from  the  postero-lateral 
angle  of  the  surface  is  seen  a  prolonged  spine  :  to  this  is  attached  the 
laxator  tympani  muscle  and  the  internal  lateral  ligament  of  the 
lower  jaw. 

The  orbital  face  of  the  wing  assists  in  forming  the  outer  boundary 
of  the  orbit ;  it  is  quadrilateral  in  form,  smooth,  and  concave.  Be- 
low, it  has  a  somewhat  rounded  border,  and  enters  into  the  forma- 
tion of  the  spheno-maxillary  fissure  ;  internally,  it  assists  in  forming 
the  sphenoidal  fissure.  At  the  lower  edge  of  the  inner  border  is  a 
delicate  spine,  giving  origin  to  one  head  of  the  external  rectus  mus- 
cle. The  foramina  generally  seen  on  this  face  are  called  orbitar 
foramina :   they  transmit  small  arteries. 

The  lesser  wings,  frequently  described  as  the  processes  of  In- 
grassias,  are  seen  on  the  encranial  surface  extending  outward,  over- 
lying at  their  apices  the  great  wings.  These  wings  are  triangular 
in  shape,  having  their  bases  associated  with  the  body  of  the  bone. 
In  articulation  they  complete  the  posterior  boundary  of  the  anterior 
fossae  of  the  cranium,  and  are  lodged  in  the  fissure  of  Sylvius.  The 
fissure  or  slit  which  separates  them  from  the  great  wings  is  called 
the  lacerated  foramen.  It  transmits  the  first  or  ophthalmic  branch 
of  the  fifth  nerve,  the  third,  fourth,  and  sixth  nerves,  and  the  ophthal- 
mic vein.  The  lesser  wings  are  connected  with  the  body  by  two 
footstalks,  inclosing  within  them  and  assisting  in  forming  the  optic 
foramina.  A  process  seen  jutting  backward  from  the  foramen  is 
called  the  anterior  clinoid  process ;  to  it  is  attached  the  common 
tendon  of  the  recti  muscles. 

The  legs  or  pterygoid  processes,  seen  falling  from  the  point  of  union 
of  the  great  wings  with  the  body,  consist  of  two  plates,  separated 
behind  by  a  deep  notch,  but  united  almost  fully  in  front.     The  ex- 


40 


ORAL  DISEASES  AND  SURGERY. 


ternal  plate  is  broad  and  curved,  and  forms  part  of  the  zygomatic 
fossa ;  to  it  is  attached  the  external  pterygoid  muscle.  The  internal 
face  forms  part  of  the  pterygoid  fossa,  and  gives  origin  to  the  inter- 
nal pterygoid.  The  internal  plate  has  a  particular  interest;  it  ends 
in  a  tubercle  or  hook-like  process,  which  is  felt  in  the  mouth  just  back 
of  the  maxillary  tuberosity.  The  hamular  process  around  it  turns  the 
tendon  of  the  tensor  palati  muscle — a  tendon  divided  in  the  operation 
for  cleft  palate.  The  base  of  this  internal  plate  forms  a  fossa,  the 
scaphoid,  from  which  originates  the  tensor  muscle  just  alluded  to. 
The  outer  surface  of  this  plate  forms  the  pterygoid  fossa;  the  inner 
surface  assists  in  forming  the  outer  posterior  boundary  of  the  nares. 

The  base  of  the  pterj^goid  process  is  quite  broad,  and  in  front  gives 
support  to  Meckel's  ganglion.    The  vidian  canal  passes  through  it. 

The  sphenoid  articulates  with  all  the  bones  of  the  cranium,  with 
the  two  malar,  the  vomer,  and  two  palate  bones  of  the  face. 

The  muscles  to  which  it  gives  origin  are  the  temporal,  external, 
and  internal  pterygoid,  tensor  palati,  laxator  tympani,  levator  pal- 
pebras,  the  recti  of  the  eye,  and  superior  oblique  of  eye. 

THE  NASAL  BONE.   ' 


ElG. 


13.— Nasal 

BOJTE. 


The  figure  exhibits  the  faces  of  a  left  nasal  bone  articulating  with 
its  fellow,  which  is  its  counterpart ;  the  two  occupy  the  quadrilateral 
space  existing  between  the  two  maxillary  bones 
and  the  frontal,  and  form  the  prominence  known 
as  the  nasal  bridge.  That  these  bones  must  vary 
considerably  in  shape  would  be  inferred  from  va- 
riations in  the  shape  of  the  bridge  so  frequently 
seen.  Looked  at  from  above  downward,  each 
bone  is  observed  to  be  concave,  while  viewed 
from  side  to  side,  it  is  convex;  several  light 
'    HiUSc  grooves   are   commonly  noticed   on  the  surface 

\jj  V?i^l  for  the  accommodation  of  vessels  ;  the  foramen 

seen  about  the  center  transmits  a  small  vein. 

The  inner  surface  reverses  relations  with  the 
outer — being  convex  from  above  below,  concave 
from  side  to  side.  Its  only  feature  of  interest  is 
a  groove  for  the  lodgment  of  the  nasal  nerve. 

The  borders  of  the  bone  are  three  articular  and 
one  free.     The  superior,  serrated  and  somewhat 
narrow,  fits   in   the  frontal   notch,  forming  the  fronto-nasal  artic- 


Anterior  view  of 
the  left  nasal  bone- 
1,  frontal  border ;  2, 
nasal  border ;  3,  maxil. 
lary  border ;  4,  lower 
border  ;  5,  nasal  fora- 
men. 


ANAT03tY  OF  THE  MOUTH  AND   FACE. 


41 


ulation.  The  lateral  border  is  beveled,  at  the  expense,  above,  of 
the  internal  plate,  below,  of  the  external,  and  fits  with  correspond- 
ing bevelings  of  the  nasal  processes  of  the  maxillary  bone.  Intern- 
ally, or  mesially,  the  bone  articulates  with  its  fellow  of  the  opposite 
side,  being-  prolonged  below  into  a  crest,  which  forms  a  part  of  the 
nasal  septum,  and  articulates  with  the  nasal  spine  of  the  frontal 
above,  and  the  ethmoidal  perpendicular  plate  below.  The  lower  border 
is  free,  at  least  so  far  as  any  bony  articulation  is  concerned,  giving 
attachment  by  a  thin,  sharp  edge  to  the  lateral  cartilage  of  the  nose. 
A  notch,  seen  at  the  center  of  this  border,  transmits  the  nerve  occu- 
pying the  groove  on  the  inner  surface. 


Fig.  14. 


-The  Malar  Bone. 

3 


THE  MALAK  BONE. 

The  malar,  or  cheek  bones,  may  be  likened  to  two  bony  pads  laid 
on  either  lateral  aspect  of  the  face  for  the  purpose  of  influencing  a 
general  convexity.  Each  bone  is  ir- 
regularly quadrilateral,  supported 
above  by  articulation  with  the  frontal, 
sphenoid,  and  superior  maxillary 
bones ;  in  front  by  the  malar  process 
of  the  maxillary  ;  posteriorly  by  the 
zygomatic  process  of  the  temporal. 

The  bone  presents  two  surfaces, 
four  processes,  and  four  borders.  The 
external  surface,  convex  and  smooth, 
presents  little  of  interest ;  the  fora- 
men, seen  upon  this  face,  has  its 
place  sometimes  occupied  by  two  or 
more ;  they  ai*e  simply  the  orifices 
of  canals,  transmitting  unimportant 
vessels.  The  surface,  in  relationship, 

is  mostly  covered  by  the  orbicularis  palpebrarum  muscle,  while  the 
zygomatic!  have  origin  from  the  lower  and  inner  aspect. 

The  internal  face  is  concave,  and  assists  in  forming,  above,  the 
temporal  fossa,  below,  the  zygomatic.  It  yields  partial  origin  to  both 
the  temporal  and  masseter  muscles. 

Of  the  four  processes,  the  orbital  is  the  most  interesting ;  turning 
at  right  angles  with  the  external  face  of  the  body,  it  assists  in  form- 
ing a  portion  of  the  outer  wall  of  the  orbit  and  orbital  ridge.  The 
frontal  is  thick  and  serrated,  and  articulates  with  the  external  angu- 


OUTER  VIEW  OF  THE  RIGHT  MALAR  BONE.   1, 

external  or  facial  surface  ;  2,  malar  fora- 
men; 3,  frontal  process;  4,  5,  orbital  bor- 
der; 6,  maxillary  border;  7,  zygomatic 
process  ;  8,  temporal  border ;  9,  inferior 
border. 


42 


ORAL  DISEASES  AND  SURGERY. 


lar  process  of  the  frontal  bone.  The  maxillary  is  rough,  and  trian- 
gular in  shape,  and  attaches  the  bone  in  front.  The  zygomatic  is 
sharp  and  flat,  and  forms  part  of  the  yoke  overlying  the  ridge  sep. 
arating  the  zygomatic  from  the  temporal  fossa. 

The  four  borders  are  the  orbital,  the  maxillary,  zygomatic,  and 
temporal.  These  borders  correspond  with  the  relations  named,  but 
have  no  interest  apart  from  the  processes. 


Fig.  15. — The  Lach- 
rymal Bone. 


THE  LACHRYMAL  BONE. 

Looking  at  the  view,  or,  much  better,  at  the  articulated  skull,  the 
lachrymal  bone  is  seen  to  occupy  a  position  of  some  prominence  in 
the  composition  of  the  orbit.  A  ridge  on  its 
anterior  surface  divides  it  into  two  parts:  one 
part,  called  its  orbital  face  (bounded  above  by 
the  orbital  face  of  the  horizontal  plate  of  the 
frontal  bone ;  laterally,  by  the  os  planum  of  the 
ethnoid ;  below,  by  the  orbital  surface  of  the 
maxillary  bone),  enters  into  the  composition 
of  the  orbital  cavity.  The  face,  to  the  inner 
side  of  the  ridge,  is  smooth  and  concave,  and 
articulates  with  the  nasal  process  of  the  max- 
illary bone,  internally,  and  with  the  lachrymal 
process  of  the  turbinated,  below ;  these  three 
bones  in  their  union  form  the  ductus  ad  nasum, 
or  lachrymal  canal,  transmitting  the  tears  to 
the  inferior  meatus. 

The  bone,  by  its  internal  or  nasal  surface, 
enters  into  the  composition  of  the  middle  me- 
atus, and  assists  in  filling  in  the  anterior  eth- 
moidal cells.     Like  the  external  surface,  it  is  divided  into  two  faces, 
the  line  of  division  being  a  depression  corresponding  with  the  ridge 
on  the  opposite  surface. 

One  muscle  has  its  attachment  to  this  bone — the  tensor  tarsi. 


EXTERSAL    VIEW    OF     THE 
EIGHT  LACHRYMAL  BONE.      1, 

orbital  surface  ;  2,  lachry- 
mal fossa ;  3,  small  process 
bounding  the  latter  infe- 
riorly ;  4,  frontal  border ; 
5,  ethmoidal  border;  6, 
maxillary  border ;  7,  pro- 
cess articulating  with  the 
turbinated  bone. 


THE  HYOID  BOXE. 

The  OS  hyoides  is  the  bone  situated  on  the  anterior  part  of  the 
neck  t)etween  the  chin  and  sternum.  In  shape  it  somewhat  resem- 
bles the  ordinary  horseshoe,  and  is  held  in  place  entirely  by  a 
series  of  antagonizing  muscles,   of  which  it  gives  attachment  to 


ANATOMY  OF  THE  MOUTH  AND   FACE. 


43 


Fig.  16. — The  Hyoid  Bone. 


1,  body 


greater  horn ;  3,  lesser 
horn. 


some  ten  pairs.  A  glance  at  the  bone  naturally  divides  it  into  a 
body  and  four  processes  or  horns  ;  the  greater  of  these  cornua  extend 
quite  widely  over  the  lateral  aspect  of 
the  neck,  giving  attachment  to  the  hyo- 
glossus,  middle  constrictor  of  the  pha- 
rynx, and  thyro-hyoid  muscles,  and  by 
a  bulb,  constituting  its  extremity,  to  the 
thyro-hyoid  ligament ;  it  also  serves  as 
our  best  guide  to  the  position  of  the 
lingualis  artery.  The  lesser  cornua  are 
simply  two  conical  eminences,  more  or 
less  prominent  on  different  specimens.  Starting  out  at  the  point  of 
junction  of  the  great  horns  with  the  body,  they  look  upward  toward 
the  chin,  and  serve  to  afford  attachment  to  the  stylo-hyoid  liga- 
ments. 

The  body  is  irregularly  quadrilateral  in  shape,  convex  in  front, 
concave  behind.  A  crucial  ridge,  the  intermuscular,  divides  the 
front  face  into  four  fossae.  This  surface  is  exclusively  devoted  to  the 
attachment  of  muscles  ;  above,  to  the  genio-hyoid  and  the  genio-hyo- 
glossus ;  below,  to  the  stylo-hyoid,  mylo-hyoid,  and  digastricus.  The 
posterior  surface  is  smooth  and  concave,  and  occupies  a  position  just 
in  front  of  the  epiglottis,  being  separated  from  it,  above,  by  some 
cellular  tissue  and  a  membrane  called,  from  its  relationship,  the 
thyro-hyoid. 


CHAPTER    II. 


THE   MOUTH. 


Studying  the  mouth  from  the  living  subject,  we  remark,  first,  an 
entrance  of  two  fleshy  folds,  the  lips  ;  separating  these,  we  are  met 
by  a  second  portal,  the  teeth  ;  the  space  existing  between  these  two 
entrances  is  called  the  hall  or  vestibule  ;  opening  this  inner  gateway, 
by  depressing  the  lower  jaw,  we  are  introduced  into  the  oral  cavity 
proper. 

The  mouth  is  the  commencement  of  the  alimentary  canal.  It  has 
as  offices,  the  reception  of  food,  gustation,  mastication,  and  insaliva- 
tion ;  eonsequentl}'  must  possess  organs  and  agencies  pertinent  to 
these  ends. 

Looking  into  the  mouth,  we  observe  that  it  is  an  oval  cavity, 
bounded  posteriorly  by  a  veil  or  curtain.  This  falls  obliquely  to- 
ward the  fauces,  having  a  central  pendulum,  terminating  laterally  in 
arched  curves.  We  can  see  beneath  this  veil,  or  between  it  and  the 
base,  and  thereby  recognize  the  cavity  we  are  viewing  to  be  simply 
the  commencement  of  a  canal.  Every  part  of  the  cavity  we  remark 
to  be  covered  by  a  common  membrane,  which  membrane  we  find 
to  associate  externally  on  the  lips  with  the  common  skin  ;  internally 
we  see  it  passing  back  of  the  veil  down  the  throat, — this  is  a  mucous 
membrane,  and  examination  reveals  it  to  be  continuous  from  this 
cavity  to  the  outlet  of  the  rectum.  The  teeth,  thirty-two  in  number 
in  the  adult,  are  placed  in  two  harmonizing  or  articulating  arches  or 
curves,  and  are,  in  shape  and  character,  correspondent  with  omniv- 
orous habits.  Thus  certain  of  their  number,  the  incisors,  as  they 
are  called,  are  so  arranged  as  to  cut  or  incise.  Certain  others,  the 
cuspidati  or  canines,  are  spear-shaped,  and  tear  or  lacerate.  Still 
others,  the  bieuspidati  and  molars,  have  broad  and  roughened  sur- 
faces, acting  the  part  of  grinders.  The  tongue,  a  muscular  body, 
rests  within  the  lower  dental  arch ;  it  evidently  is  fitted  and  suited 
to  preside  over  the  labor  of  the  teeth,  receives  or  rejects  articles  to 
be  comminuted,  places  and  retains  such  articles  in  position  to  be 
(44) 


THE  MOUTH.  ^  45 

masticated,  and,  when  ready  to  be  swallowed,  rolls  up  masses  into 
boluses,  and  passes  them  into  the  pharynx. 

The  roof  of  the  cavity,  beginning  with  the  palatine  faces  of  the 
teeth,  is  made  up  evidently  of  hard  and  soft  tissues.  The  hard  por- 
tion we  discover  to  be  the  flesh-covered  alveolar  and  palatine  pro- 
cesses of  the  superior  maxillary  bones  and  the  palate  processes  of 
the  palate  bone.  The  soft  portion  dissection  reveals  to  be  a  simple 
attached  basement  tissue  covered  with  the  common  membrane. 

Continuing  to  look  for  a  short  period  into  the  mouth,  we  observe 
that  jets  of  fluid  are  occasionally  sent  up  from  the  anterior  floor  just 
back  of  the  lower  central  teeth.  We  also  see  drops  constantly  issuing 
from  an  orifice  situated  on  the  cheek  by  the  side  of  the  superior 
second  molar  tooth.  This  fluid  is  the  salivary  secretion,  and  comes 
from  glands  situated  in  the  immediate  neighborhood.  Besides  this 
salivary  fluid,  pearly  drops  are  seen,  more  or  less  plainly,  over  the 
surface  of  the  common  mucous  membrane.  This  is  mucus,  and  is 
the  product  of  the  follicles,  crypts,  or  glands  of  the  common  mem- 
brane. 

The  mouth,  then,  we  may  say  is  made  up  of,  and  invites  a  study 
of,  the  lips,  cheeks,  gums,  teeth,  mucous  membrane,  tongue,  hard 
and  soft  palate,  and  salivary  glands ;  and  if  we  accept,  as  indeed 
surgically  we  must,  that  the  cavity  begins  with  the  lips  and  ends 
at  the  posterior  wall  of  the  pharynx,  then  we  include  in  the  study 
all  the  relations  which  belong  to  the  posterior  entrance. 

The  lips  and  cheeks  are  alike  in  their  composition,  and  are  truly  a 
part  and  parcel  of  each  other.  First,  in  the  dissection,  we  have  a 
layer  of  skin  on  the  outside  and  a  layer  of  mucous  membrane  on 
the  inside.  Removing  the  skin,  we  expose  a  layer  of  cellular  fascia, 
in  which  is  more  or  less  fatty  tissue.  This  superficial  fascia,  as  it 
is  called,  differs  from  other  fasciae  of  the  same  signification,  in  not 
being  a  distinct  or  laminated  tissue.  It  is  intimately  connected  with 
the  skin,  and  more  intimately  associated  wuth  the  muscles.  Re- 
moving this,  a  complex  grouping  of  muscles  is  exposed, — the  muscles 
of  expression. 

The  view  (Fig.  17)  expresses  so  fully  the  position  and  signification  of 
these  muscles  that  it  scarcely  seems  necessary  to  enter  on  any  descrip- 
tion of  them.  The  orbicular,  or  sphincter  of  the  lips,  may,  however,  be 
specially  noted,  as  its  influence  is  concerned  in  retracting  wounds  of 
the  part.  In  studying  the  muscles  of  the  face,  it  will  be  observed 
that  they  naturally  arrange  themselves  into  groups.    Thus  we  have 


46 


ORAL  DISEASES  AND  SURGERY. 


a  group  that  are  elevators,  another  that  are  depressors.  Then 
groups  that  pertain  to  particular  regions,  as  the  nasal,  superior 
maxillary,  inferior  maxillary,  intermaxillary,  etc.  Surgically,  how- 
ever, the  information  they  possess  is  sufficiently  elicited  in  com- 
prehending their  general  plan  and  arrangement. 

Situated   upon,  and  running  among  these  muscles,  we  have  the 

Fig.  17. — Muscles  of  the  Face. 


Muscles  of  the  head  and  neck.  1,  2,  occipito-frontal  muscle:  1,  its  frontal  belly;  2,  its 
occipital  belly;  3,  nasal  pyramidal  muscle;  4,  superior,  and  5,  posterior  auricular  mus- 
cles; 7,  labio-nasal  elevator;  8,  elevator  of  the  upper  lip;  9,  nasal  compressor;  10,  11, 
zygomatic  muscles ;  12,  masscter  muscle ;  13,  buccinator ;  14,  depressor  of  the  oral  angle ; 
15,  oral  orbicular  muscle  ;  16,  elevator  of  the  oral  angle ;  17, 18,  depressor  of  the  lower 
lip ;  19,  sterno-mastoid  muscle ;  20,  trapezius ;  21,  posterior  belly  of  the  digastric  and  the 
stylo-hyoid  muscle ;  22,  anterior  belly  of  the  former ;  23,  loop  of  fibrous  tissue  attach- 
ing the  tendon  of  the  digastric  muscle  to  the  hyoid  bone;  24,  omo-hyoid  nmscle;  25, 
sterno-hyoid ;  26,  sterno-thyroid,  seen  to  the  outer  side  and  behind  the  anterior  belly  of 
the  omo-hyoid;  27,  mylo-hyoid ;  28,  splenius;  29,  elevator  of  the  scapular  angle;  30,31, 
middle  and  anterior  scalene  muscles;  32,  clavicle. 


arteries  of  the  face.     These  are  all  branches  of  the  external  divi- 


THE  MOUTH. 


47 


sion  of  the  common  carotid,  and  will  be  found  in  the  dissections 
distributed  exactly  as  seen  in  the  view.  The  facial,  the  third 
branch  of  the  carotid  externus,  is  observed  to  cross  over  the  lower 
jaw  just  in  front  of  the  masseter  muscle;  and,  in  the  subject,  is  seen 
to  emerge  from  or  beneath  the  submaxillary  gland,  generally  pass- 
ing through  its  substance.  Its  branches  are  ten  in  number;  four 
are  offshoots  from  its  cervical  portion;  six  are  facial.     The  facial 

Fig.  18. — Arteries  of  the  Face. 


The  EXTERNAL  CAROTID  ARTERY  AND  ITS  BRANCHES.  1,  right  coiiiuion  Carotid;  2,  internal 
carotid;  3,  external  carotid;  4,  superior  thyroid;  5,  lingual ;  6,  facial;  7,  submental ;  8, 
inferior  coronary;  9,  superior  coronary;  10,  muscular  branches;  11,  lateral  nasal  artery  ; 
12,  angular  artery;  13,  occipital  artery;  14,  descending  cervical;  15,  muscular  branch; 
16,  posterior  auricular  artery ;  17,  parotid  branches  ;  18,  internal  maxillary ;  19,  temporal ; 
20,  tranverse  facial ;  21,  anterior  auricular ;  22,  supraorbital ;  23,  middle  temporal ;  24, 
anterior  temporal ;  25,  posterior  temporal  artery. 


branches  are,  first,  the  inferior  labial,  which  passes  forward  under  the 
depressor  anguli  oris,  and  supplies  the  lower  part  of  the  lip,  anasto- 
mosing with  all  the  subjacent  vessels,  the  submental,  inferior  coro- 
nary, and  inferior  dental  arteries.  The  coronaries — the  second  and 
third  of  these  branches — penetrate  the  substance  of  the  underlying- 
muscles,  and  pass  around  the  lips  immediately  beneath  the  mucous 


48 


ORAL  DISEASES  AND  SURGERY. 


membrane  ;  their  pulsations  may  be  very  plainly  felt ;  in  many  per- 
sons these  vessels  are  of  such  large  size  as  to  render  hemorrhage 
from  them  a  matter  of  some  trouble  to  control. 

The  lateralis  nasi,  the  fourth  of  the  branches,  ascends  along  the 
side  of  the  nose,  supplying  its  aloe  and  dorsum.  The  fifth,  the 
angular,  passes  between  the  inner  canthus  and  nasal  bridge.  It 
gives  off  sub-branches  to  the  orbicularis  muscle,  to  the  lachrymal 
sac,  and  to  the  integument  of  the  suborbital  region,  and  finally 
loses  itself  in  an  anastomosis  with  the  ophthalmic  artery.    A  point 

Fig.  19. — The  Common  Carotid,  with  its  Divisions. 


;::v4isi:iiiM'*^^ 


Left  COMMON  carotid  dividixg  into  the  external  and  internal  carotid  arteries.  1, 
common  carotid  artery ;  2,  internal  carotid ;  3,  external  carotid ;  4,  superior  thyroid ;  5, 
lingual ;  6,  pharyngeal  artery ;  7,  facial ;  8,  inferior  palatine  and  tonsillar  arteries ;  9,  sub- 
maxillary; 10,  sulimental ;  11,  occipital;  12,  posterior  auricular;  13,  parotid  branches; 
14,  internal  maxillary;  1.5,  temporal  artery;  16,  subclavian  artery;  17,  axillary;  18,  ver- 
tebral artery ;  19,  thyroid  axis  ;  20,  inferior  thyroid  giving  off  the  ascending  cervical ;  21, 
transverse  cervical;  22,  suprascapular;  23,  internal  mammary  artery. 


in  the  view  to  observe  is,  that  the  inferior  and  all  the  mesial  line  of 
the  face  are  supplied  by  branches  of  a  common  trunk,  and  that  this 
trunk  is  compressible  on  the  lower  jaw  just  in  front  of  the  masseter 
muscle,  facial  hemorrhage  being  thus  perfectly  under  control  by  com- 
pression. 


THE  310  UTH. 


49 


THE    NEPvYES   OF   THE    FACE. 


This  view  beautifully  exhibits  the  distribution  of  the  branches  of 
the  facial  nerve.    The  main  trunk,  seen  emerging  just  below  the  lobe 


Fig.  20. — Nerves  of  the  Face. 


1,  trunk  of  the  nerve  emerging  at  tlio  stvlo-mastoid  foramen;  2,  its  deep  auric- 
ular branch ;  .3,  anastomosis  of  the  latter  with  the  great  auricular  nerve  of  the  cer- 
vical plexus ;  4,  5,  6,  branches  to  the  contiguous  muscles ;  7,  8,  branches  of  the  facial 
to  the  digastric  and  stylo-hyoid  muscles;  9,  temporo-facial  division  of  the  nerve;  10, 
branch  to  the  temple,  anastomosing  with  the  auriculo-temporal  nerve;  11,  temporal 
branches;  12,  zygomatic  branches;  13,  infraorbital  branches;  14,  15,  cervico-facial  divi- 
sion of  the  facial  nerve  ;  14,  buccal  branches ;  16,  inferior  maxillary  branches ;  17,  cervical 
branches;  18,  auriculo-temporal  nerve;  19,20,  terminal  branches  of  the  frontal  nerve; 
21,  terminal  branch  of  the  lachrymal  nerve ;  22,  external  nasal  nei-ve ;  23,  branch  of  the 
temporo-malar  nerve ;  24,  terminal  branch  of  the  internal  nasal  nerve ;  2.5,  infraorbital 
nerves ;  26,  anastomosis  between  the  buccal  branch  of  the  inferior  maxillary  nerve  and 
the  buccal  branches  of  the  facial  nerve ;  27,  terminal  branches  of  the  inferior  dental  nerve  ; 
28,  great  occipital  nerve  ;  29,  31,  branches  of  the  great  auricular  nerve  ;  30,  small  occipital 
nerve  ;  32,  superficial  cervical  nerve,  anastomosing  with  the  facial  nerve. 


50  ORAL  DISEASES  A. YD   SURGERY. 

of  the  car,  in  front  of  the  anterior  border  of  the  stcrno-eleido-mas- 
toideus,  is  the  portia  dura,  or  hard  portion  of  the  seventh  nerve,  the 
motor  nerve  acting  on  the  muscles  of  expression.  The  nerve  arises 
from  the  medulla  oblongata,  passes  outward  over  the  crus  cerebelli, 
and  enters  the  auditory  meatus  with  the  soft  or  auditory  portion  ; 
passing  to  the  bottom  of  this  meatus,  it  enters  the  Fallopian  aque- 
duct, follows  the  serpentine  course  of  this  canal  until  it  arrives 
at  the  stylo-mastoid  foramen,  whence  it  emerges,  as  seen  upon  the 
outside  of  the  face.  While,  however,  in  the  temporal  bone,  the 
nerve  connects  with  several  others,  and  forms  a  ganglion,  the  intu- 
mescentia  gangliformis,  as  it  is  called. 

Issuing  from  the  stylo-mastoid  foramen,  the  facial  associates  with 
the  pneumogastric,  glosso-pharyngeal,  carotid  plexus,  auricularis 
magnus,  and  auriculo-temporal.  Passing  to  the  face,  it  unites  with 
the  three  divisions  of  the  fifth  nerve. 

In  front  of  the  ear  the  nerve  is  seen  to  divide  into  two  primary 
divisions  or  trunks,  the  temporo-facial  and  cervico-facial.  The  tem- 
poral, the  larger  of  the  two,  passes  through  the  parotid  gland, 
crosses  the  neck  of  the  lower  jaw,  and  divides  into  three  sets  of 
branches,  distributed  to  the  temporal,  malar,  and  infraorbital  regions. 
The  cervico-facial  passes  downward  and  forward  through  the  gland, 
and  divides  into  buccal,  supra-  and  inframaxillary  branches.  The 
manner  of  distribution  and  anastomoses  is  perfectly  shown  in  the 
dissection. 

THE   VEIXS   OF   THE   FACE. 

The  veins  of  the  face  will  be  seen  to  correspond  quite  closely 
with  the  arterial  distribution.  Surgically  they  are,  however,  of 
little  import,  as  it  is  seldom  that  wounds  of  them  are  of  sufficient 
consequence  to  command  any  direct  attention ;  they  pass  their  blood 
into  one  or  another  of  the  three  jugulars,  being  not  by  any  means 
constant  in  the  selection.  Between  them  all,  however,  the  most 
thorough  anastomosis  is  always  found  to  exist,  thus  rendering  it 
really  of  little  consequence  what  may  be  the  direct  downward  course 
of  the  current.  The  veins  of  the  antero-exterior  head  are  the  facial, 
the  temporal,  the  internal  maxillary,  and  temporo-maxillary. 

The  facial,  commencing  at  the  inner  angle  of  the  orbit,  is  formed 
by  the  confluence  of  the  supraorbital,  palpebral,  nasal,  and  angular 
veins.  It  commences  its  course  downward  and  outward,  passing 
beneath  the  zygomatic  muscles,  receiving  the  superior  and  inferior 
labial  veins,  the  buccal,  and  masseteric ;  passes  to  the  base  of  the 


THE  MOUTH.  51 

jaw,  receiving  just  below  it  the  submental,  the  inferior  palatine,  the 
submaxillary,  and  ranine  veins,  and,  finally,  with  a  great  branch,  re- 

FiG.  21. — Veins  of  the  Face. 


Veins  of  the  head  and  neck.  1,  frontal  vein ;  2,  nasal  vein ;  3, 4,  labial  veins ;  5,  facial 
vein ;  6,  lingual  vein ;  7,  internal  jugular  vein ;  8,  9,  posterior  and  anterior  temporal  veins  ; 
10,  transverse  facial  vein;  11,  internal  maxillary  vein;  12,  posterior  auricular  vein  ;  13, 
external  jugular  vein  ;  14,  posterior,  15  anterior  jugular  veins,  a,  external  carotid  artery; 
6,  eterno-mastoid  muscle;  c,  trapezius;  d,  pectoral  muscle;  e,  deltoid  muscle. 

ceived  from  the  temporo-maxillary,  loses  itself  in  the  deep  jugular. 
The  temporal  commences  by  a  plexus  on  the  side  of  the  head  and 


52  ORAL  DISEASES  AXD   SURGERY. 

vertex,  passes  downward  in  front  of  the  ear,  receives  the  transverse 
facial,  posterior,  auricular,  occipital,  and  deep  maxillary  veins,  enters 
the  substances  of  the  parotid  gland,  and,  finally,  being  enlarged  by 
these  various  branches,  becomes  the  external  jugular. 

The  internal  or  deep  maxillary  is,  in  its  origin,  a  series  of  veins 
collecting  the  blood  from  the  parts  supplied  by  the  internal  maxil- 
lary artery  and  adjacent  parts.  These  various  veins,  the  middle 
meningeal,  deep  temporal,  pterygoid,  masseteric,  buccal,  and  inferior 
dental,  forming  the  common  trunk,  empty  into  the  temporal. 

The  temporo-maxillary  is  simply  the  name  given  to  that  part  of 
the  temporal  vein  below  the  point  of  entrance  of  the  maxillary — 
either  name  is  used  with  equal  propriety. 

SECTIOXAL   EXPRESSION   OF   MOUTH. 

The  view  (Fig.  22)  represents  a  section  directly  through  the  center 
of  the  skull  from  before  backward,  and  perfectly  exhibits  the  char- 
acter of  the  mouth  and  its  associations.  Below  is  seen  the  tongue 
in  its  relations,  in  front,  to  the  genial  turbercles ;  behind,  to  the  epi- 
glottis. A  fossa  between  the  root  of  this  organ  and  the  epiglottis, 
one  each  side  of  a  common  center,  the  fraenum  epiglottis,  is  particu- 
larly worthy  of  note,  as  it  is  a  frequent  receptacle  for  fish  bones  and 
other  foreign  bodies,  giving  sometimes  much  trouble  in  their  re- 
moval. The  free  surface  of  the  tongue  is  seen  to  be  convex,  while 
the  section  reveals  its  common  body  to  be  triangular  with  the  apex, 
looking  forward. 

The  roof  of  the  mouth,  seen  above,  is  remarked  to  be  a  quite  thin 
plane,  forming  as  well  the  floor  of  the  nose.  Its  relation  to  the  oral 
cavity  is  concave,  but  differing  widely  in  various  persons,  being  in 
some  almost  flat,  in  others  very  deep.  The  anterior  portion,  bony, 
will  be  recognized  as  being  formed  by  the  palatine  processes  of  the 
maxillary  and  palate  bones ;  the  posterior  portion,  soft,  veil-like,  and 
movable,  is  the  velum,  terminating  in  the  uvula  in  the  center,  just 
above  and  in  front  of  the  tip  of  the  epiglottis ;  laterally,  in  two 
pillars  or  half  arches,  called  respectively  the  anterior  and  posterior 
pillars.  The  first  of  these — the  one  seen  in  the  view  as  associating 
itself  with  the  tongue — is  formed  by  the  projection  of  the  palato- 
glossus muscle ;  the  second,  or  posterior,  is  the  projection  likewise 
of  a  muscle,  the  palato-pharyngeus,  passing  from  the  veil  to  the 
pharynx;  the  fossa  existing  between  these  pillars  lodges  the  tonsil 
gland.     The  hard  portion  of  the  palate  or  oral  roof  is  frequently  the 


THE  MOUTH.  53 

seat  of  necrosis ;  it  will  be  remarked  that  only  the  smallest  loss  of 
substance  is  required  to  associate  the  two  cavities.     The  isthmus  of 


Fig.  22. — Sectional  View  of  the  Nose,  ]\[oitth,  Pharynx. 


Vertical  section  of  the  face  and  neck,  through  the  median  line  antero-posteriorly, 

EXPOSING   TO   VIEW   THE   NOSE,   MOUTH,   PHARYNX,  AND   LARYNX.      1,  OVal  cartilage  of  the  left 

nostril;  2,  triangular  cartilage;  3,  line  of  separation  between  the  two;  4,  prolongation  of 
the  oval  cartilage  along  the  column  of  the  nose ;  5,  superior  meatus  of  the  nose ;  6,  middle 
meatus ;  7,  inferior  meatus ;  8,  sphenoidal  sinus ;  9,  posterior  i)art  of  the  left  nasal  cavity, 
communicating  with  tlie  pharynx ;  10,  orifice  of  the  Eustachian  tube  ;  11,  upper  extremity 
of  the  pharynx ;  12,  soft  palate,  ending  below  in  the  uvula ;  13,  interval  of  the  mouth  be- 
tween the  lips  and  jaws  ;  14,  roof  of  the  mouth,  or  hard  palate  ;  15,  communication  of  the 
cavity  of  the  mouth  with  the  interval  between  the  jaws  and  cheek ;  16,  tongue ;  17,  fibrous 
partition  in  the  median  line  of  the  latter;  18,  genio-glossal  muscle;  19,  genio-hyoid 
muscle  ;  20,  niylo-hyoid  muscle  ;  21,  anterior  half  arch  of  the  palate  ;  22,  posterior  half 
arch  of  the  palate ;  23,  tonsil ;  24,  25,  floor  of  the  fauces ;  26,  27,  pharynx  ;  28,  cavity  of 
the  larynx;  29,  ventricle  of  the  larynx;  30,  epiglottis;  31,  hyoid  bone;  32,  33,  thyroid 
cartilage;  34,  thyro-hyoid  membrane;  35,  36,  cricoid  cartilage;  37,  vocal  membrane. 

the  fauces,  the  space  between  the  two  arches,  is  bounded,  above,  by 
the  margin  of  the  palate  ;  below,  by  the  base  of  the  tongue  ;  laterally, 
by  the  half  arches  and  amygdalae. 


54  ORAL   DISEASES  AND  SURGERY. 

The  Tonsils— The  tonsils  are  glandular  organs,  situated  one  on 
cither  side  of  the  isthmus.  These  bodies  are  made  up  of  many  lob- 
ules, having  many  sulci  lined  by  involutions  of  the  common  mucous 
membrane.  They  arc  not  unfrequcntly  the  seat  of  such  hypertrophy 
as  to  make  necessary  their  amputation,  while  in  their  sulci  may  lodge 
debris,  which,  in  its  retention  and  decomposition,  becomes  one  of  the 
sources  of  an  unpleasant  breath.  Externally  these  bodies  are  in 
very  close  relation  with  the  internal  carotid  arteries,  a  point  neces- 
sary to  be  kept  in  remembrance  in  performing  operations  on  them. 

The  relationship  of  a  bolus  of  food  Avith  the  pharynx,  and  its 
direction,  over  the  chink  of  the  glottis  into  the  oesophagus,  by  the 
epiglottis,  is  clearly  exhibited  by  the  drawing. 

The  Tongue. — Dissection  of  the  tongue  reveals  it  to  be  a  some- 
what complex  body,  although  made  up  in  the  great  mass  of  its  bulk 
by  muscular  substance.  Attached  to  the  inferior  maxillary  bone  in 
front,  and  to  the  hyoid  behind,  it  yet  moves  with  the  greatest  free- 
dom and  latitude  in  either  direction,  giving  us  the  idea  that  if  it  is 
muscular  substance,  it  must  be  free  muscle  set  upon  fixed  muscles, 
and  this  is  practically  the  case  as  is  understood  by  studying  a  dis- 
section. 

The  muscular  structure  of  the  tongue  is  made  up  of  five  distinct 
pairs  and  certain  non-attached  fasciculi.  The  body,  as  its  surface  is 
concerned,  is  seen  with  a  base  looking  backward  into  the  fauces, 
and  a  tip,  which  represents  the  apex  of  a  pyramid.  Beginning 
the  study  of  the  organ  with  its  relations  to  the  hyoid  bone,  we 
remark,  first,  that  from  this  bone  arises  a  muscle,  the  hyoglossus, 
which,  passing  almost  directly  upward,  enters,  with  the  stylo-glossus, 
the  root  of  the  body,  and  expands  itself  laterally  and  forward. 
Passing  toward  the  center  of  the  bone,  we  remark  a  second  muscle, 
the  genio-hyoglossus,  which,  having  apparent  origin  from  the  genial 
tubercles,  radiates  downward  and  upward,  attaching  one  of  its 
wings  to  the  os  hyoides,  the  other  spreading  out  to  assist  in  the 
formation  of  the  tongue.  The  stylo-glossus,  the  third  muscle,  arises 
from  the  styloid  process  of  the  temporal  bone,  passes  downward 
and  forward,  and  occupies  or  makes  up  either  lateral  aspect  from 
the  tip  to  the  bone.  The  fourth,  the  lingualis,  seen  between  the 
stylo-glossus  and  genio-hyoglossus,  passes  from  the  tip  to  the  base, 
having,  indeed,  some  few  of  its  fibers  continued  to  the  os  hyoides. 
The  fifth,  the  palato-glossus,  is  the  muscle  of  the  anterior  half  arch; 
it  assists  in  forming  the  base  and  side.  The  unattached  fibers  are 
certain  longitudinal  and  transverse  bands  running  through  the  sub- 


THE  MOUTH. 


55 


stance  of  the  organ.  The  tongue,  as  an  organ  of  nutrition,  is 
adapted  most  happily,  through  its  muscular  character,  to  preside 
over  the  acts  of  mastication,  and,  this  process  completed,  to  transfer 
the  comminuted  mass  back  into  the  grasp  of  the  pharyngeal  con- 


FiG  23  — Upper  Surface  of  the  Tongue. 


1,  2,  V-like  row  of  the  circumviillatc  papillas  3,  capitate  papillaj ;  4,  5,  conical  i)a- 
pillse ;  6,  G,  floor  of  the  fauces,  with  numerous  simple  follicular  glands ;  7,  tonsils ;  8, 
summitjof  the  epiglottis ;  9,  the  middle  glosso-epiglottic  frsenum,  with  depressions  on  each 
side  bounded  externally  by  the  lateral  frseua. 

strictors.     Its  ability  and  variety  of  action  is  comprehended  by  a 
single  moment's  observation  of  the  study  exhibited  in  a  dissection. 
Fig.  23,  exhibiting  the  magnified  upper  surface  of  the  organ,  dis- 


56 


ORAL   DISEASES  AND   SURGERY 


covers  it  covered  with  mucous  membrane,  clotted  here  and  there  with 
more  or  less  regularly  located  papillae,  of  varying  size  and  character. 

The  mucous  membrane  envelops  the  tongue  wherever  the  body 
has  free  surface.  Above,  it  is  dense,  and  affords  support  to  numerous 
papillffi;  below,  it  is  exceedingly  delicate,  and  is  traceable  through 
the  ducts  of  the  submaxillary  and  sublingual  glands. 

The  papillae,  seen  upon  the  dorsum,  are  cone-shaped  projections  of 
homogeneous  tissue,  holding  arteries,  veins,  and  nerves  in  plexiform 
arrangement ;  they  are  located  in  three  distinct  sets,  each  having 
distinctive  features. 

The  most  posterior  are  the  largest,  and  occupy  a  position  which 
very  much  resembles  the  letter  V ;  they  may  be  likened  to  inverted 
cones,  the  apices  resting  in  cup-shaped  depressions  of  the  mucous 
membrane,  hence  surrounded  each  by  a  valley.     They  are  various])^ 

Figs.  24  axd  25. — Papillae  of  Tongue. 


Diagram  of  the  papill.5  of  the  tongue,  modPi-attly  iiiagiilfiod.  1,  capitato  papilla; ;  2, 
conical  papilla;;  3,  epithelium;  4,  the  same  structure  forming  bunches  of  hair-like  pro- 
cesses; 5,  connective  tissue. 


Papill*  of  the  tongue,  highly  magnified.  1,  conical  papillae  ;  2,  capitate  papilla; ;  3, 
simple  papillae,  occupying  the  intervals  of  the  compound  papilla; ;  4,  epithelium  ascending 
from  the  conical  papillaj  in  hair-like  processes ;  5,  isolated  epithelial  scales  from  the 
latter. 


named  the  maximce  or  circumvallatffi.     Of  this  class  there  are  some 
fifteen  ;  the  elevated  margins  of  the  fossa  surrounding  these  papillae 


THE  MOUTH.  57 

are  studded  with  secondary  papillae.  The  structure  of  these  bodies 
is  accurately  exhibited  in  the  magnified  drawing. 

The  papillifi  fungiformes  or  mediae  are  scattered  somewhat  irreg- 
ularly over  the  sides  and  apex  of  the  organ  ;  they  are  exceedingly 
vascular,  and  closely  covered  with  secondary  papillae  ;  are  broad  and 
rounded  on  their  free  surfaces,  narrow  and  pointed  at  their  attach- 
ment to  the  tongue  ;  their  middle  size  and  red  color  easily  dis- 
tinguish them.  The  magnified  fungiform  papillae  are  seen  in  the 
drawing. 

The  smallest  or  filiform  papillae  follow  somewhat  in  their  arrange- 
ment the  order  of  the  maximse,  being  interspersed  among  the  fungi- 
formes.  They  are  very  minute,  and  covered  so  deeply  with  epithe- 
lium as  to  appear  quite  white  ;  they  are  enveloped  with  secondary 
papillae,  as  exhibited  in  the  figure. 

In  the  tongue,  beside  these  papillae  are  found  also  numerous  mu- 
cous glands  ;  these  bodies,  scattered  over  the  whole  surface,  secrete 
the  ordinary  mucus  ;  they  differ  in  no  respect  from  mucous  glands 
wherever  situated.  In  the  valleys  surrounding  the  maxima  papillae 
these  glands  are  found  in  larger  number  than  in  any  other  portion 
of  the  organ. 

A  transverse  section  exhilMts  the  tongue  as  composed  of  two  sym- 
metrical halves,  separated  from  each  other  by  a  fibrous  septum,  each 
half  consisting,  as  we  have  seen,  of  muscular  structure,  supplied  with 
vessels  and  nerves,  and  having,  in  most  cases,  much  interposed  fat. 

The  tongue,  being  an  organ  of  both  special  and  common  sense,  is 
furnished  with  nerves  of  both  signification.  Thus  the  papillae,  at  the 
apex  and  sides,  are  supplied  with  the  gustatory  filaments  from  the 
third  branch  of  the  fifth  nerve  ;  the  great  papillae  and  base  of  the 
organ,  from  filaments  of  the  glosso-pharyngeal ;  the  muscular  struc- 
ture, from  the  hypoglossal. 

The  arteries  of  the  tongue  are  the  lingual,  branches  of  the  facial, 
and  ascending  pharyngeal.  The  one  of  most  signification  is  the  first. 
Each  vessel  anastomoses  with  its  fellow,  just  above  the  fr»num, 
on  the  under  surface  of  the  organ,  and  is  liable  to  be  opened  in  the 
operation  for  tongue-tie.  This  artery  is  the  second  branch  from  the 
external  carotid ;  it  pursues  a  course  parallel,  for  a  short  distance, 
with  the  great  horn  of  the  hyoid  bone  lying  between  it  and  the  hypo- 
glossal nerve.  "Wounds  of  the  tongue  occasionally  make  the  vessel 
at  this  point  the  seat  of  ligation. 

The  epiglottis,  seen  by  depressing  the  dorsum,  forms,  practi- 
cally, the  base  of  the  organ,  being  supported  in  the  center  by  a  bridle, 


58  ORAL  DISEASES  AND   SURGERY. 

the  frtenum  epiglottis,  and  at  either  side  by  two  duplications  of  the 
lingual  mucous  membrane,  the  glosso-epiglottic  ligaments  or  folds. 
as  they  are  called ;  these  boundaries  form  two  lateral  depressions  or 
fossae,  fossae  lingualis,  noticed  as  being  so  frequently  the  seat  of  the 
lodgment  of  foreign  particles. 

The  Gums. — See  Diseases  of  the  Gums. 

The  Mucous  Membrane.  —  Practically  considered,  the  oral 
mucous  membrane  is  to  be  viewed  as  commencing  at  the  lips  and 
terminating  at  the  anus,  so  much  is  it  in  sympathy  part  with  part. 
Anatomically,  we  view  this  membrane  as  consisting  of  a  plane  of 
homogeneous  tissue,  underlaid  by  its  vascular  supply,  the  vessel 
being  supported  b}'  and  in  cellular  tissue.  This  basement  mem- 
brane gives  support  to  a  covering  of  squamae  or  scales,  known  as 
the  epithelium,  and  covers  in  tissues  or  organs  which  have  offices 
of  a  recrementitial  nature. 

The  tissues,  beside  the  vascular,  which  underlie  the  mucous  mem- 
brane,  are  the  nerves,  lymphatics,  and  the  papillary  structure.  The 
epithelium,  the  enveloping  tissue,  is  singularly  various  in  its  char- 
acter, being  sometimes  columnar,  again  squamous,  again  ciliated. 

Commencing  at  the  alveolar  margin  of  the  lower  jaw,  this  mem- 
brane passes  over  the  floor  of  the  mouth,  envelops  the  tongue  on 
all  its  free  surface,  forming  beneath,  by  its  duplications,  the  frsenum 
lingua ;  from  the  back  of  the  organ  it  is  so  reflected  as  to  form  the 
three  glosso-cpiglottidial  folds ;  from  this  it  lines  the  pharynx  and 
larynx,  and  is  then  continued  over  the  digestive  and  respiratory 
tracks,  lining,  in  the  latter,  the  very  terminal  vesicles. 

The  mucous  cysts  or  follicles,  so  plentifully  scattered  over  the 
oral  mucous  surface,  have,  as  their  office,  the  secretion  of  a  limpid 
fluid,  which  is  commonly  to  be  seen  standing  over  the  membrane  as 
drops  of  cold  sweat  are  observed  on  the  forehead  in  typhoid  condi- 
tions, the  two,  indeed,  looking  very  similar.  The  constituents  of 
mucus  are  water,  the  peculiar  organic  principle  called  mucosiu,  and 
alkaline  salts.  Mucous  glands  are  variously  named,  according  to 
their  location,  as  glandulae  labiales,  buccales,  etc. 

Columnar  epithelium  consists  of  rod-like  particles,  bulged  near 
the  center  by  a  nucleus,  crowded  closely  together ;  this  variety  is 
found  in  the  air-passages,  on  the  intestinal  villi,  in  the  bile  duct,  and 
elsewhere.  The  scaly  is  found  in  the  alimentary  tract  as  low  as  the 
stomach.  The  glandular  seems  a  constituent  of  all  the  glands, 
being  made  up  of  particles  bulky  and  globular.  Ciliated  epithelium 
is  the  columnar  variety  clothed  with  secondary  particles. 


THE  MOUTH.  59 

THE   SALIVARY   GLAXDS. 

The  salivary  glands  are  of  the  conglomerate  order,  and  are  very 
well  represented  by  an  ordinary  bunch  of  grapes.  There  is,  first,  a 
great  number  of  lobules,  each  lobule  being  a  miniature  gland ;  from 
these  come  ducts,  or  channels  of  outlet,  representing  the  grape- 
stems  ;  these  all  are  associated  with  a  common  branch  or  duct, 
which  is  the  channel  of  outlet  into  the  mouth. 

The  parotid,  the  largest  of  the  salivary  glands,  is  situated  in  the 
hollow  between  the  external  ear  and  ramus  of  the  inferior  maxillary 
bone.  Its  weight  varies  considerably  in  different  individuals,  the 
mean,  however,  being  in  the  neighborhood  of  an  ounce.  The  bound- 
ary of  the  gland  above  is  the  zygoma ;  below,  a  line  carried  directly 
across  from  the  angle  of  the  jaw  to  the  sterno-mastoid  muscle.  Dis- 
sected from  its  bed,  the  organ  is  found  quite  deeply  seated ;  it  ex- 
tends above  into  the  glenoid  fossa  of  the  os  temporis,  and  below 
rests  upon  the  styloid  process  and  muscles,  extending  forward  to  the 
space  between  the  two  pterygoid  muscles.  The  gland  is  exceedingly 
vascular,  having  imbedded  in  it  the  external  carotid  artery,  which, 
in  its  substance,  divides  into  the  temporal,  internal  maxillary,  trans- 
verse facial,  and  posterior  auricular.  The  temporo-maxillary  vein 
also  traverses  the  structure,  while  the  deep  jugular  and  the  internal 
carotid  artery  lie  very  close  to  its  deep  surface;  it  is  also  pierced  by 
the  facial  and  great  auricular  nerves.  Externally,  the  gland  is 
smooth,  and  has  its  lobes  protected  by  a  covering,  very  similar  in 
appearance  to  the  pia  mater  of  the  brain.  Upon  this  covering  lie 
two  lymphatic  ganglia,  the  enlargement  of  which  is  often  mistaken 
for  disease  of  the  gland  itself.  Covering  the  gland  is  the  parotid 
fascia,  a  reflection  simply  of  the  common  deep  fascia  of  the  neck, 
the  platysma  myoides,  fascia  superficialis,  and  skin.  The  gland 
empties  its  secretion  into  the  mouth  through  a  duct  known  as  that 
of  Steno.  This  passes  across  the  face  between  the  superficial  fascia 
and  muscles,  perforating  the  buccinator  opposite  the  second  molar  of 
the  upper  jaw.  A  line,  designating  the  position  of  the  duct,  and 
which  is  most  important  to  be  remembered,  is  drawn  from  the  lobe 
of  the  ear  to  the  middle  of  the  upper  lip.  This  duct  is  quite  dense, 
is  about  the  diameter  of  a  crow-quill,  and  is  some  two  inches  in 
length  ;  it  consists  of  three  coats — an  external  or  fibro-muscular,  an 
internal  or  mucous,  lined  with  ciliated  epithelial  scales,  and  a  mid- 
dle or  cellular  coat. 

The  submaxillary,  the  second  in  size  of  the  salivary  glands,  is 


60  ORAL   DISEASES  AND   SURGERY. 

situated  beneath  the  lower  jaw  in  the  superior  cervical  triangle, 
resting,  in  part,  in  the  submaxillary  fossa.  The  gland  is  some- 
what of  the  size  and  shape  of  an  almond-hull,  and  has  a  weight  of 
two  or  three  drachms ;  it  is  completely  enveloped  by  a  triangular 
envelope,  made  by  two  leaves  of  the  deep  fascia  attached  below  to 
the  digastric  tendon.  Directly  upon  the  gland,  and  within  the  envel- 
ope, are  two  lymphatic  ganglia,  which  are  quite  liable  to  take  on  in- 
flammatory enlargement ;  these  glands  I  take  to  be  pretty  constant, 
as  I  have  examined  many  subjects  for  them,  and  mostly  with  the 
common  result  of  seeing  them.  The  so-called  extirpation  of  the 
submaxillary  gland  is,  most  generally,  the  removal  of  one  of  these 
bodies  enlarged  from  inflammatory  action;  these  ganglia  may  be 
surgically  viewed  as  being  strictly  non-vascular,  a  ligature  being 
seldom  needed  in  operations  upon  them.  The  gland  itself,  on  the 
contrary,  is  very  vascular,  the  facial  artery  passing  frequently 
directly  through  its  substance,  or  so  closely  connected  with  the  lower 
surface  as  to  compel  the  division  of  it,  or  some  of  its  large  vessels, 
before  the  body  can  be  raised  from  its  bed;  the  lingualis  also  sends 
branches  to  it,  while  its  veins  correspond  with  the  arteries.  The 
gland  is  closely  in  relation  with  the  parotid,  behind,  and  the  lingual, 
in  front,  being  separated  from  the  first  by  the  stylo-maxillary  liga- 
ment, and  from  the  latter  by  the  mylo-hyoid  muscle.  The  duct 
by  which  the  gland  conveys  its  secretion  to  the  mouth  is  some  two 
inches  in  length  ;  it  passes  between  the  mylo-hyoid  and  genio-hyoid 
muscles,  and  opens  by  the  side  of  the  fraenum  lingua.  It  is  the  most 
common  seat  of  ranula.     The  duct  is  called  Wharton's  duct. 

The  sublingual  is  the  smallest  of  the  three  glands  ;  it  lies  directly 
beneath  the  mucous  membrane,  being  between  it  and  the  m34o-hyoid 
muscle  ;  its  weight  is  about  one  drachm  The  exact  position  of  the 
gland,  as  it  lies  at  the  lateral  aspect  of  the  symphysis,  can  be  seen 
by  raising  the  tip  of  the  tongue ;  its  bulk  will  be  noticed  by  elevating 
the  mucous  membrane,  upon  which  its  excretory  ducts,  some  twenty 
in  number,  open ;  these  ducts  are  called  ductus  Riviniani,  and  are  dis- 
tinguished from  one  or  more,  called  the  Bartholin,  opening  into  or 
near  Wharton's  duct.  The  lingual  gland,  when  diseased,  may  fre- 
quentl}'  be  removed  with  very  little  hemorrhage.  I  have  extirpated 
it  without  using  a  ligature. 


THE  MOUTH. 


61 


TEMPORO-MAXILLAEY   ARTICULATION". 

The  inferior  maxillary  bone  articulates  with  the  anterior  portion 
of  the  glenoid  cavity  of  the  temporal,  forming  what  is  known  as  an 
arthrodial  or  gliding  joint.  The  direct  composition  of  this  joint 
consists  of  the  convex  condyloid  head  of  the  maxillary  bone,  the 
concave  surface  of  the  glenoid  fossa,  interarticular  fibro-cartilage,  a 
double  synovial  membrane,  and  a  loose  capsular  ligament.  (See 
engraving.) 


Figs.  26  and  27. — Vertical  Section  of  Temporo-Maxillary  Artic- 
ulation. 


Vertical  section  of  the  aeticdla- 

TION    OF    THE    LOWER    JAW.      1,    is    placed 

above  the  glenoid  cavity  ;  2,  glenoid 
cavity ;  3,  iuterarticnlar  cartilage  di- 
viding the  joint  into  two  cavities,  4  and 
5;  6,  an  interarticular  cartilage  sepa- 
rated from  a  joint,  to  exhibit  its  form. 


External  view  op  the  temporo-maxillart 
articulation.  1,  zygoma ;  2,  glenoid  tulierelc ; 
3,  ramus  of  the  inferior  maxillary  bone ;  4, 
mastoid  process ;  5,  external  lateral  liga- 
ment; 6,  stylo-maxillary  ligament,  a  process 
of  the  cervical  fascia. 


The  double  character  of  the  glenoid  fossa,  with  its  fissure  of 
division,  its  articulating  eminence  in  front,  and  the  cartilage-cov- 
ered condyle  of  the  maxillary  bone,  must  be  understood  by  looking 
at  the  bones.  The  view  represents  the  parts  in  position  and  physi- 
ological relation.  Above  is  seen  the  glenoid  cavity ;  below,  the  con- 
dyle of  the  inferior  maxilla;  between,  the  interarticular  fibro-carti- 
lage, with  a  synovial  or  lubricating  membrane  lining  each  aspect  of 
the  joint:  the  back  part  of  a  common  capsular  ligament  is  also  seen, 
which,  when  complete,  would  be  exhibited  as  enveloping  the  whole 
joint.  Back  of  the  section,  as  shown  in  the  view,  is  that  portion  of 
the  cavity  which  lodges  the  upper  part  of  the  parotid  gland. 

The  capsular  ligament  is  an  exceedingly  loose  sac,  very  much, 
indeed,  like  the  capsule  of  the  humero-scapular  articulation ;  it  is 


62  ORAL   DISEASES  AND   SURGERY. 

attached  above  to  the  circumference  of  the  glenoid  cavity,  and  in 
front  to  the  articular  root  of  the  zj'goma ;  below,  it  clasps  the  neck 
of  the  bone  just  beneath  the  head. 

The  interarticular  fibro-cartilage  is  an  ovoid  plate  placed  between 
the  two  bones ;  it  is  supported  in  its  position  by  a  more  or  less  per- 
fect circumferential  attachment  to  the  common  capsule,  the  external 
lateral  ligament,  and  to  the  tendon  of  the  external  pterygoid  muscle  : 
below,  its  face  is  concave,  corresponding  with  the  convexity  of  the 
condyle ;  above,  it  is  concave  in  front,  convex  behind,  corresponding 
with  the  glenoid  cavity  proper,  and  the  eminentia  articularis.  In 
composition  the  circumference  is  markedly  fibrous,  shading  off  to  a 
cartilaginous  center,  frequently  quite  soft,  and  sometimes  perforated. 

The  synovial  membranes,  placed,  as  seen  in  the  view,  one  above, 
the  other  below  the  interarticular  fibro-cartilage,  are  the  ordinary 
lubricating  membranes  of  closed  cavities ;  they  may  very  well  be 
likened  to  two  simple  bags,  with  parietal  attached  faces.  These 
bags  secrete  the  synovia,  a  fluid  which  looks  not  unlike  the  white 
of  an  e^^,  but  which  is  much  more  oily  and  resistive  in  its  nature. 

From  the  spinous  process,  seen  on  the  great  wing  of  the  sphenoid 
bone,  a  ligament,  the  internal  lateral,  descends  to  be  attached  to  the 
inner  face  of  the  ramus.  Behind,  from  the  styloid  process  of  the 
OS  temporis,  a  second,  the  stylo-maxillary,  passes  to  be  inserted  just 
above  the  angle. 

The  external  lateral  ligament  is  a  short,  somewhat  triangular- 
shaped  band  of  fibrous  tissue,  having  origin  from  the  zygoma;  pass- 
ing obliquely  downward  and  backward,  and  inserted  about  the  neck 
of  the  condyle,  just  below  the  head,  it  lies  in  contact  with  the  lateral 
aspect  of  the  interarticular  fibro-cartilage,  and  really  assists  in  form- 
ing, or  at  least  thickening,  the  common  capsule.  Externally,  it  is 
quite  superficial,  being  only  covered  by  the  integuments,  except  in 
instances  where  the  upper  border  of  the  parotid  gland  spreads  over 
it.  The  importance  of  the  character  of  this  articulation  renders 
necessary  its  careful  study  by  personal  dissection. 


CHAPTER    III. 


FIFTH   PAIR   OP    NERVES. 


The  fifth  is  an  encephalic  nerve — that  is,  coming  off  from  that  por- 
tion of  the  cerebro-spinal  center  lying  within  the  cranium.  Called  the 
fifth,  because  this  is  the  order  of  its  emergence;  called  also  trifa- 
cial, because,  while  within  the  cranium,  it  divides  into  three  portions, 
which  portions,  in  their  divisions  and  subdivisions,  are  distributed 
respectively  to  the  superior,  middle,  and  inferior  portions  of  the 
facial  region  ;  called  also  "  trigeminus,"  a  name  derived  from  tri, 
three,  and  geminus,  twin,  or  double,  signifying  literally  three  double, 
triple,  referring  to  its  threefold  divisions. 

The  fifth,  trifacial  or  trigeminus,  is  first  discovered  as  a  number  of 
filaments,  of  which  there  are  two  distinct  sets,  coming  off  from  the 
sides  of  the  pons  Varolii ;  this  is  called  its  superficial  origin.  The 
deep,  or  true  origin,  can  be  traced  into  the  substance  of  the  pons  as 
far  as  the  lateral  tract  of  the  medulla  oblongata.  These  filaments  of 
origin  are  called  the  roots  of  the  nerve,  and,  being  twofold,  afford  the 
likeness  which  exists  between  this  particular  encephalic  nerve  and 
those  of  the  spinal  cord. 

The  fifth  nerve  is  peculiar  in  being  both  compound  and  special : 
that  is  to  say,  it  supplies  parts  with  filaments  of  sensation,  fila- 
ments of  motion  ;  and  through  one  of  its  branches,  called  the  "gusta- 
tory," with  filaments  which  pertain  to  the  sense  of  taste.  It  is  the 
great  sensitive  nerve  of  the  head  and  face ;  the  nerve  of  motion  to 
the  muscles  of  mastication ;  the  nerve  of  the  sense  of  taste  to  the 
anterior  part  of  the  tongue.    (See  Function  of  Nerve.) 

Immediately  on  the  emergence  of  the  roots  from  the  points  of  their 
superficial  origin,  they  pass  through  a  slit-like  opening  in  the  dura 
mater  at  the  apex  of  the  petrous  portion  of  the  temporal  bone.  Here 
the  larger  root,  called  the  sensor,  enters  a  ganglion,  lying  in  a 
fossa  on  the  anterior  face  of  this  triangular  apex,  the  Gasserian  or 
semilunar. 

The  ganglion  of  Gasser  is  a  small,  reddish-gray  semilunar  knot 
enveloping  apparently  the  great  or  posterior  root  of  the  fifth  nerve 

(63) 


64 


ORAL   DISEASES  AND  SURGERY 


as  it  passes  over  the  temporal  apex ;  its  size  is  equal  perhaps  to 
that  of  an  ordinary  buckshot,  although  from  its  flattened  and  cres- 
centic  form,  the  measurement  from  tip  to  tip  of  its  horns  would  sur- 
pass somewhat  the  diameter  of  such  a  shot.  The  convex  face  of 
the  ganglion  looks  forward. 


Fig 


Trifacial  Division  and  Ganglia. 


Trifacial  ner^i,  tin  un    '  1  "  '  '  '""^ '  rtmoved.  1,  semilunar 

ganglion;  2,  oplitliilniit  ntnt ,  3,  l.itliijm<tl  ni.i\t.,  4,  liont.il  nei\e ,  5,  6,  its  two  princi- 
pal branches ;  7,  a  branch  passing  from  the  orbital  above  tne  pmiey  of  tne  superior  oblique 
muscle ;  8,  nasal  ner\'e ;  9,  its  external  nasal  branch ;  10,  course  of  the  internal  nasal  nerve 
from  the  orbit  into  the  cranium,  and  nose  ;  11, 12, 13,  temporal  branches  of  the  inferior  max- 
illary nerve  ;  14,  commencement  of  the  auriculo-tomporal  nerve ;  15,  greater  petrosal  uervo. 
I.  olfiictory  nerve ;  II,  optic  nerves ;  III,  oculo-niotor  nerve ;  IV,  pathetic  nerve  to  the 
superior  oblique  muscle  of  the  eye ;  V,  trifacial  nerve ;  Its  small  root  visible  beneath  the 
cut  end  of  the  large  root,  wliich  forms  the  semilunar  ganglion  dividing  into  the  ophthal- 
mic, superior  and  inferior  maxillary  nerves ;  VI,  abducent  nerve ;  Vll,  facial,  included  in 
a  groove  of  the  auditory  nerve,  VIII,  both  entering  the  auditory  meatus ;  IX,  glosso- 
pharyngeal, X,pneumogastric,  and  XI,  accessory  nerves  emerging  at  the  jugular  foramen; 
XII.  hypoglossal  nerve. 

On  emerging  from  this  ganglion,  the  posterior  root  is  found  di- 
vided into  three  cords — the  three  primarj'  divisions  of  the  sensitive 
portion.  The  first  of  these  cords  constitutes  what  is  called  the 
ophthalmic  nerve,  or  the  ophthalmic  portion  or  division  of  the  fifth 
nerve.     The  second  cord,  the  superior  maxillary  nerve,  or  superior 


THE  FIFTH  PAIR    OF  NERVES.  65 

roaxillaiy  division  of  the  fifth.  The  third,  the  inferior  maxinary 
nerve. 

The  first  of  these  nerves  has  its  distribution  over  the  orbito-frontal 
region. 

The  second  has  its  distribution  over  the  superior  maxillary 
region. 

The  third  associates  with  the  lesser  or  motor  root,  which  root 
first  connects  with  it  at  the  base  of  the  skull,  and  has  its  distribution 
over  the  inferior  maxillary  region. 

Ophthalmic  Nerve. 

This  division  of  the  fifth  passes  from  the  Gasserian  ganglion  along 
the  outer  wall  of  the  cavernous  sinus,  and  enters  the  orbit  through 
the  sphenoidal  fissure  ;  before  entering  which,  however,  it  breaks 
up  into  three  branches.  These  branches  supply  the  eyeball,  the 
lachrymal  gland,  the  mucous  lining  of  the  nose,  and  the  muscles 
and  the  integument  of  the  forehead.  They  are  called  frontal,  lachry- 
mal, nasal.  The  ophthalmic  is  the  smallest  of  the  three  divisions 
of  the  fifth.  It  is  a  flattened  band  not  more  than  an  inch  in  length, 
receiving,  before  breaking  up  into  its  terminal  branches,  filaments 
from  the  carotid  plexus  of  the  sympathetic,  and  giving  off  two  or 
more  filaments,  which,  with  a  branch  from  the  fourth  nerve,  pass 
between  the  layers  of  the  tentorium. 

The  Frontal  Bi^anchia  the  largest  of  the  divisions  of  the  ophthalmic, 
and  is  commonly  regarded  as  the  continuation  of  the  nerve.  In  the 
orbit  it  lies  above  the  levator  palpebrse  muscle,  between  it  and  the 
periosteum,  dividing  about  midway  of  the  cavity  into  two  branches — 
supratrochlear  and  supraorbital. 

The  supratrochlear  branch  passes  inward  to  the  pulley  of  the 
superior  oblique  muscle,  giving  off  here  descending  filaments  which 
anastomose  with  similar  trochlear  filaments  from  the  nasal  nerve. 
A  second  or  terminal  branch  passes  from  the  orbit  between  the 
superior  oblique  and  supraorbital  foramen,  ascends  behind  the  cor- 
rugator  supercilii  and  occipito-frontalis  muscles,  to  both  of  which  it 
distributes  filaments,  and  is  finally  lost  in  the  integument  of  the 
forehead. 

The  su]3raorbital  branch  or  division  of  the  frontal  passes  forward 
until  it  reaches  the  supraorbital  foramen,  when  it  passes  out  unto 
the  forehead.  In  this  situation  it  gives  off  a  number  of  filaments  to 
the  upper  eyelid,  called  palpebral.     In  its  distribution  over  the  fore- 

5 


66  ORAL  DISEASES  AND   SURGERY. 

head,  it  sends  branches  to  the  orbicularis  palpebrarum,  occipito- 
frontalis,  and  corrugator  supercilii  muscles,  anastomosing  in  the 
first  named  muscles  with  filaments  of  the  facial  nerve.  Other  two 
sets  of  terminal  filaments  supply,  the  first,  the  periosteum  covering 
the  frontal  and  parietal  bones ;  the  second,  the  integument,  as  far 
back  as  the  occiput. 

The  Lachrymal. — This  is  the  smallest  of  the  three  divisions  of 
the  ophthalmic.  It  is  almost  always  accompanied  by  filaments  from 
the  fourth  nerve.  In  the  orbit  it  connects  itself  with  the  orbital 
branch  of  the  second  or  superior  maxillary  division  of  the  fifth 
nerve.  Its  distribution  is  to  the  lachrymal  gland,  the  conjunctiva, 
and  the  integument  of  the  upper  eyelid,  in  which  last  situation  it 
joins  with  filaments  of  the  facial  nerve. 

The  Nasal. — This  division  is  intermediate  in  size  between  the 
frontal  and  lachrymal.  Entering  the  cavity  of  the  orbit  between 
the  two  heads  of  the  external  rectus,  it  passes  directly  across  the 
optic  nerve  to  the  anterior  of  the  ethmoidal  foramina;  through  this 
foramen  it  passes  into  the  cavity  of  the  cranium,  where  it  traverses 
the  shallow  groove  on  the  front  of  the  cribriform  plate  of  the  eth- 
moidal bone,  until  arriving  at  the  nasal  slit  it  passes  directly  down- 
ward into  the  nose,  terminating  in  two  branches.  Of  these  two 
branches,  the  external  descends  on  the  inner  surface  of  the  nasal 
bone,  supplying  the  mucous  membrane  of  its  neighborhood ;  leaving 
the  cavity  at  the  juncture  of  the  bone  wnth  the  lateral  cartilage,  it 
passes  on  the  external  part  of  the  nose  down  to  supply  the  integu- 
ment of  the  lips,  and  join  with  the  facial  nerve.  The  second  branch, 
the  internal,  supplies  the  mucous  membrane  about  the  front  of  the 
septum. 

In  the  orbital  cavity  are  given  oif  three  branches  from  the  nasal — 
the  ganglionic,  ciliary,  and  infratrochlear. 

The  ganglionic  is  a  slender  cord,  about  half  an  inch  in  length, 
which  is  the  sensor  filament  to  the  orbital  or  ophthalmic  ganglion. 
(See  Ganglia.)  i 

The  ciliary,  called  long  ciliary,  to  distinguish  them  from  certain 
shorter  branches,  called  also  ciliary,  given  off  from  the  ophthalmic 
ganglion,  are  two  or  three  in  number,  and,  in  association  with  the 
short  ciliary,  pierces  the  posterior  face  of  the  sclerotic,  and,  passing 
between  this  coat  and  the  choroid,  are  distributed  to  the  ciliary 
muscle  and  iris. 

The  infratrochlear  branch  is  given  off  just  as  the  main  portion 
passes  into  the  ethmoid  foramen,  joining  beneath  the  pulley  of  the 


THE  FIFTH  PAIR    OF  NERVES. 


67 


superior  oblique  muscle,  with  a  filament  of  the  supratrochlear  nerve ; 
this  branch  continues  to  the  inner  angle  of  the  eye,  where  it  is  dis- 
tributed to  the  orbicular  muscle,  the  integument  of  the  eyelid,  and 
side  of  the  nose,  to  the  conjunctiva,  caruncula  lachrymal  is  and 
lachrymal  sac. 

Recapitulation. — The  ophthalmic  or  first  division  of  the  fifth 
nerve  supplies  the  tentorium,  lachrymal  gland,  caruncula  lachry- 
malis,  lachrymal  sac,  ciliary  muscle  and  iris,  muscles  of  eyelid  and 
forehead,  integument  of  forehead  and  nose,  mucous  membrane  of 
eye  and  nose,  and  pericranium  of  frontal  and  parietal  regions. 

Fig.  29. — Superior  Maxillary  Nerve. 


The  external  wall  of  the  left  orbit  and  op  the  superior  maxillary  bone  removed. 

I,  superior  maxillary  nerve  iu  its  course  througli  the  infraorbital  canal ;  2,  3,  posterior 
dental  nerves ;  4,  anterior  dental  nerve ;  5,  anastomosis  between  the  dental  nerves ;  6, 
spheno-palatine  ganglion;  the  branch  from  the  superior  maxillary  nerve  above  is  the 
commencement  of  the  temporo-malar  nerve ;  7,  pterygoid  nerve ;  8,  greater  petrosal 
nerve  joining  the  facial  nerve ;  9,  deep  petrous  nerve  joining  the  carotid  plexus  of  the 
sympathetic ;  10,  abducent  nerve  with  its  communicating  branches  of  the  latter  jjlexus  ; 

II,  superior  cervical  ganglion ;  12,  ascending  branches  to  the  carotid  plexus ;  13,  facial 
nerve ;  14,  glosso-pharyngeal  nerve ;  15,  the  tympanic  nerve ;  16,  branch  to  the  carotid 
plexus ;  17, 18, 19,  branches  to  the  round  and  oval  windows  and  Eustachian  tube ;  20, 
branch  to  the  smaller  petrosal  nerve,  21. 


This  nerve  or  division  arises,  as  a  flattened  band,  from  the  middle 
of  the  Gasserian  ganglion.  It  passes  forward  over  the  greater  wing 
of  the  sphenoid  bone,  until,  reaching  the  foramen  rotundum,  it  leaves 
the  cranium,  and  presents  itself  in  the  spheno-m axillary  fossa;  from 
this  fossa  it  passes  to  the  orbital  cavity,  through  the  spheno-maxil- 
lary  fissure,  where,  being  lodged  in  the  infraorbital  canal,  it  con- 
tinues forward  to  the  points  of  its  ultimate  distribution. 


68  ORAL  DISEASES  AND   SURGERY. 

Branches  of  Distribution— 1.  In  the  spheno-maxillary  fossa— 
three  in  number— orbital,  ganglionic,  posterior  dental. 

The  orbital  enters,  with  the  main  branch  of  the  nerve,  the  orbital 
cavity,  and  divides  into  two  branches,  temporal  and  malar.  The 
temporal  branch  passes  from  the  orbit  through  a  foramen  in  the 
malar  bone,  and  enters  the  temporal  fossa ;  it  here  perforates  the 
temporal  muscle  and  fascia,  and  is  distributed  to  the  integument 
covering  the  side  of  the  head,  and  associates  with  the  facial  nerve, 
and  an  ascending  branch,  auriculo-temporal,  of  the  inferior  max- 
illary. The  malar  branch  leaves  the  orbit  also  through  a  foramen 
in  the  malar  bone,  perforates  the  orbicularis  palpebrarum  muscle, 
and  joins  with  a  branch  of  the  facial. 

Ganglionic,  two  in  number. — They  drop  directly  down  into  the 
spheno-palatine,  or  Meckel's  ganglion;  hence  are  commonly  known 
as  the  spheno-palatine  branches. 

Posterior  Dental. — This  branch  arises  from  the  trunk  just  as  it 
enters  the  orbit ;  it  instantly  breaks  up  into  an  anterior  and  posterior 
portion.  The  first  supplies  the  gums  and  buccinator  muscle;  the 
second  pierces  the  tuberosity  of  the  maxillary  bone,  and,  after  form- 
ing a  minute  plexus  above  the  alveolus,  distributes  filaments  to  each 
of  the  posterior  teeth ;  its  termination  is  lost  in  a  union  with  the 
anterior  dental  nerve. 

2.  In  the  Infraorbital  Canal. — One.  The  anterior  dental.  This 
branch  is  given  off  about  midway  of  the  canal.  It  enters  a  second 
canal  existing  on  the  anterior  face  of  the  maxillary  sinus,  and  curv- 
ing backward,  associates  itself,  as  above  alluded  to,  with  the  pos- 
terior dental ;  from  the  curve  are  given  off  filaments  to  the  anterior 
teeth — incisors,  canines,  and  bicuspidati. 

3.  On  the  Face. — Three.  Palpebral,  nasal,  labial.  These  are  the 
terminal  filaments,  the  division  occurring  as  the  nerve  issues  from 
the  infraorbital  foramen.  The  palpebral  filaments  pass  up  to  the 
supply  of  the  orbicularis  palpebrarum  muscle  and  the  integument 
and  conjunctiva  of  the  lower  eyelid ;  at  the  outer  angle  of  the  orbit 
they  associate  with  the  malar  branch  of  the  orbital  and  filaments  of 
the  facial  nerve.  The  nasal  filaments  pass  across  the  nose,  supply- 
ing the  muscles  and  integument  of  this  region;  they  usually  join  at 
the  tip  with  the  nasal  branch  of  the  ophthalmic.  The  labial  fila- 
ments pass  downward  beneath  the  levator  labii  superioris,  and  are 
distributed  to  the  muscles  and  integument  of  the  upper  lip,  to  the 
mucous  membrane  of  the  mouth,  and  to  the  labial  glands.  The 
intricate  plexus  situated  in  the  canine  fossa  is  formed  of  filaments 


THE  FIFTH  PAIR    OF  NERVES. 


69 


from  the  facial  nerve  associating  with  twigs  of  the  trimaxiUary 
division. 

Recapitulation. — The  superior  maxillary  nerve,  or  second  division 
of  the  fifth,  supplies  the  integument  on  the  side  of  the  head,  Meckel's 
ganglion  with  its  sensor  filaments,  the  teeth,  the  antrum,  orbicularis 
palpebrarum  muscle,  integument  and  conjunctiva  of  lower  eyelid, 
muscle  and  integument  of  nose,  muscles,  integument,  and  mucous 
membrane  of  superior  lip  and  labial  glands. 

Fig.  30.— Inferior  Ma.xiillary  Nkrve. 


Distribution  of  the  inferior  maxillary  nerve.  1,  muscular  branch  to  the  masseter 
muscle ;  2,  5,  7,  branches  to  the  temporal  muscle ;  3,  branch  to  the  buccinator,  anasto- 
mosing with  one  from  the  facial  at  4 ;  6,  external  pterygoid  muscle ;  8,  auriculo-temporal 
nerve ;  9,  branches  to  the  temple ;  10,  branches  to  the  ear ;  11,  its  anastomosis  with  the 
facial ;  12.  lingual  nerve ;  1-3,  branch  to  the  mylo-hyoid  muscle  from  the  inferior  dental 
nerve,  14  ;  15,  branches  to  the  teeth  ;  16,  terminal  branches  to  the  lower  lip  and  chin. 


This  nerve  or  division  is  the  largest  of  the  three,  and  constitutes, 
justly  speaking,  the  only  portion  of  the  fifth  nerve  compound  in 
character.     The  sensor  portion  is  the  third  of  the  cords  emerging 


70  ORAL  DISEASES  AND   SURGERY. 

from  the  Gassorian  gan^^liou;  the  motor  portion  is  that  lesser  root 
alluded  to  as  coming  off  from  the  pons  Varolii ;  the  sensor  cord  falls 
quickly  into  the  oval  foramen  of  the  sphenoid  bone,  through  which 
it  passes  from  the  cranium.  The  motor  cord,  which  has  passed 
forward  beneath  the  Gasserian  ganglion,  unites  with  the  sensor  just 
as  it  emerges  from  this  foramen.  Here  then  is  made,  b}^  this  union, 
a  single  cord,  the  perfected  or  compound  inferior  maxillary  nerve — a 
nerve  made  up  of  filaments  of  motion  and  filaments  of  sensation. 
At  the  point  of  juncture  of  these  two  cords  is  found  a  little  ganglion, 
the  otic.  (See  Ganglia.) 

Immediately  beneath  the  base  of  the  skull,  this  compound  inferior 
maxillary  nerve  divides  into  two  branches — anterior  and  posterior. 
Into  the  anterior  branch  passes  most  of  the  motor  filaments. 

The  anterior  branch  breaks  up  into  five  divisions,  and  is  dis- 
tributed to  the  muscles  of  mastication.  These  divisions  or  branches 
receive  names  from  the  parts  supplied  by  them;  they  are  the  mas- 
seteric, buccal,  deep  temporal,  and  pterygoid. 

The  posterior  branch  is  the  larger  of  the  two  divisions ;  it  sub- 
divides into  three  parts.  These  supply  the  inferior  teeth,  tongue, 
and  auriculo-tcmporal  region.  Hence  the  branches  are  named  in- 
ferior dental,  lingual,  and  auriculo-tcmporal. 

Divisions  of  Anterior  Branch. — 3Iasseteric.  —  This  branch 
runs  across  the  sigmoid  notch  of  the  inferior  maxillary  bone,  enters 
the  substance  of  the  masseter  muscle,  and  is  distributed  in  it.  In 
crossing  the  notch  it  occasionally  gives  off  a  filament  to  the  artic- 
ulation. 

Deep  Temporal  Branches. — They  are  two  in  number.  They  pass 
under  the  temporal  muscle,  and  supply  its  deep  surface. 

Buccal. — This  branch  pierces  the  external  pterygoid  muscles, 
passes  down  beneath  the  coronoid  process  of  the  jaw,  pierces  the 
fibers  of  the  temporal  muscle,  and,  reaching  the  buccinator,  divides 
upon  it  into  a  superior  and  inferior  branch.  The  superior  supplies 
the  upper  part  of  the  muscle  and  the  integument ;  the  inferior  sup- 
plies the  lower  part  of  the  muscle  and  its  lining  mucous  membrane. 

Pterygoid  Branches. —  Two  in  number.  One  supplying  each 
pterygoid  muscle. 

Divisions  op  Posterior  Branch. — Auriculo- Temporal. — This 
branch  passes  out  to  the  inner  side  of  the  temporo-maxillary  articu- 
lation, turns  upward  in  company  with  the  temporal  artery ;  and  on 
emerging  with  this  vessel  from  beneath  the  parotid  gland,  divides 
into  two  branches.     The  posterior  of  the  two  supplies  the  attrahens 


THE  FIFTH  PAIR    OF  NERVES.  71 

auren,  the  pinna,  and  the  neighboring  integument.  The  anterior 
passes  upward  with  the  terminal  branches  of  the  artery,  and  is  dis- 
tributed to  the  temporal  integument.  Branches  of  communication 
exist  between  the  auriculo-temporal  nerve,  the  facial,  and  the  otic 
ganglion.  The  articulation,  the  parotid  gland,  and  the  external 
auditory  meatus  receive  nerve  endowment  from  the  auriculo-tem- 
poral. 

Lingual  or  Gustatory. — This  branch  is  a  nerve  of  special  sense, 
presiding  in  part  over  the  action  of  taste  ;  its  terminal  filaments,  as 
might  be  inferred,  are  distributed  extensively  to  the  papillae  and 
mucous  membrane  of  the  tongue.  Of  the  three  sets  of  papillas,  the 
filiform  and  fungiform,  or  those  situated  on  the  anterior,  two-thirds 
of  the  organ  receive  the  principal  supply,  the  posterior  or  great 
papillae  being  supplied  from  the  glosso-pharyngeal.  On  this  account 
it  was  deduced  that  the  gustatory  presided  over  taste  only  as  the 
anterior  two-thirds  of  the  tongue  was  concerned;  and  which  in- 
ference has  been  abundantly  borne  out  by  vivisection.  (See  Todd 
and  Bowman, pa^es  385,  86,  87,  88,  89,  and  90.)  In  the  dissection, 
the  gustatory  branch  is  seen  coming  off  just  opposite  the  sigmoid 
notch.  In  company  with  the  inferior  dental  nerve,  or  branch,  it 
passes  down  along  the  inner  side  of  the  ramus,  until,  leaving  the 
dental  somewhat  above  the  posterior  dental  canal,  it  crosses  obliquely 
to  the  side  of  the  tongue,  along  which  it  pursues  its  way  to  its  points 
of  final  termination,  anastomosing  at  the  tip  of  the  organ  with  fila- 
ments of  the  hypoglossal.  In  its  course  it  lies  first  beneath  the 
external  pterygoid  muscle,  crosses  the  internal  pterygoid,  rests  upon 
the  superior  constrictor  of  the  pharynx,  runs  over  Wharton's  duct, 
where  it  reaches  the  apex  of  the  tongue.  In  its  course,  branches  of 
communication  are  given  off  to  the  submaxillary  ganglion  and  the 
hypoglossal  nerve. 

Inferior  Dental  Nerve  or  Branch. — This  is  the  largest  of  the 
three  divisions  of  the  inferior  maxillary  nerve.  Between  its  point 
of  origin  and  entrance  into  the  dental  canal,  it  gives  off  a  branch, 
the  mylo-hyoid,  distributed  to  the  mjdo-hyoid  and  anterior  belly  of 
the  digastric  muscles.  The  main  portion,  after  entering  the  poste- 
rior foramen  of  the  dental  canal,  pursues  its  way  beneath  the  teeth, 
giving,  in  its  course,  filaments  to  all  these  organs,  terminating  finally 
in  a  branch,  the  mental,  which  passes  from  the  canal  at  the  mental 
foramen,  and  has  its  distribution  in  the  muscular  and  cutaneous  sub- 
stance of  the  inferior  lip. 

Recapitulation. — The  inferior  maxillary  nerve,  or  third  division  of 


72 


ORAL  DISEASES  AND   SURGERY. 


the  fifth,  supplies  the  muscles  of  mastication,  the  auriculo-temporal 
region,  the  anterior  two-thirds  of  the  tongue,  the  mylo-hyoid  and  di- 
gastric muscles,  the  inferior  teeth,  and  the  muscles  and  skin  of  the 
lower  lip. 

Ganglia  of  the  Fifth  Pair  of  Nerves. 

Associated  with  the  fifth  nerve  are  six  ganglia :  they  are  called 
Gasserian;  ophthalmic,  lenticular  or  ciliary;  Meckel's  or  spheno- 
palatine ;  naso-palatine  or  ganglion  of  Cloquet ;  otic ;  submaxillary. 

Ganglion  of  Gasser. — This  ganglion,  called  as  frequently  the 
semilunar,  from  its  shape,  is  found  lying  in  a  slight  depression  on 
the  anterior  face,  near  the  apex  of  the  petrous  portion  of  the  tem- 
poral bone.  It  receives  the  posterior  or  sensor  cord  of  the  fifth 
nerve,  and  transmits  it  divided  into  three  parts.  The  ganglion  re- 
ceives filaments  from  the  carotid  plexus  of  the  sympathetic,  and 
gives  ofi"  filaments  to  the  tentorium  cerebelli,  and  to  the  dura  mater 
of  the  middle  fossa  of  the  cranium. 


Fig.  31. — Ophthalmic  Gaxgliox — the  Outer  Part  of  the  Eight  Orbit 

Eemoved. 


1,  optic  nerve;  2,  ocnio-motor  nerve;  3,  branch  to  the  superior  straight  and  oWiqne 
muscles;  4,  branch  to  the  inferior  oblique  muscle;  5,  abducent  nerve  to  the  external 
straight  muscle;  6,  trifacial  nerve,  its  ganglion  and  three  principal  branches  ;  7,  ophthal- 
mic nerve;  8,  nasal  nerve ;  9,  ophthalmic  ganglion;  10,  its  communicating  branch  with 
the  oculo-motor  nei-ve ;  11,  do.  with  the  ophthalmic  nerve ;  12,  do.  with  the  carotid  plexus 
of  the  sympathetic ;  13,  the  ciliarj'  nerves ;  14,  frontal  nerve. 

Ophthalmic,  Lenticular  or  Ciliary  Ganglion. — This  ganglion,  as 
implied  in  its  name,  is  found  in  the  cavity  of  the  orbit.  It  is  a  small, 
quadrangular,  flattened  body,  not  larger,  generally,  than  the  ordinary 
pin  head;  it  is  situated  between  the  external  rectus  muscle  and  optic 
nerve,  well  enveloped  in  the  mass  of  fat  found  occupying  this  portion 


THE  FIFTH  PAIR    OF  NERVES. 


73 


of  the  cavity.  Its  branches  of  communication  are  derived,  the  first, 
or  sensor,  from  the  nasal ;  the  second,  or  motor,  from  the  third  nerve ; 
the  third,  or  sympathetic,  from  the  cavernous  plexus.  Its  branches 
of  distribution  are  the  short  ciliary  nerves.  These  nerves,  ten  or 
twelve  in  number,  arise  from  the  anterior  face  of  the  ganglion,  being 
connected,  as  two  sets  of  filaments,  with  the  superior  and  inferior 
angles.  The  two  sets  pass  forward,  one  being  above,  the  other  below 
the  optic  nerve,  until,  reaching  the  sclerotic  coat  of  the  eye,  they 
penetrate  this  organ,  and  are  distributed  to  the  ciliary  muscle  and  iris 

Fig.  32. — Vie"w  of  tue  Spheno-Palatine  Ganglion,  the  Outer  Wall 
or  THE  Left  Nasal  Cavity,  and  the  Olfactory  Nerve. 


\\ 


1,  olfactory  nerve;  2,  nasal  branch  of  the  ophthalmic  nerve;  3,  spheno-palatine  gan- 
glion ;  4,  5,  6,  palatine  nerves ;  7,  branch  to  the  nose ;  8,  nasal  nei've  to  the  outer  wall  of 
the  nose  ;  9,  do.  to  the  inner  wall ;  10,  pterygoid  nerve  ;  11,  facial  nerve ;  12,  deep  petrous 
nerve  joining  the  carotid  plexus;  13,  the  other  branch  of  the  pterygoid  is  the  larger  pe- 
trosal nerve,  which  joins  the  facial. 


MeckeVs  Ganglion — Spheno-Palatine. — This  is  the  largest  and 
most  extensively  connected  of  the  cranial  ganglia.  Its  position  is 
in  the  spheno-maxillary  fossa,  immediately  in  front  of  the  vidian 
foramen.  In  shape  it  is  triangular,  and  in  color  reddish-gray.  Its 
branches  of  communication  are  derived,  the  first,  or  sensor,  from  the 
superior  maxillary  nerve,  which,  as  has  been  seen,  gives  to  it  two 
filaments  while  crossing  the  fossa.  The  second,  or  motor,  from  the 
facial  nerve,  or  rather  from  the  intumescentia  gangliformis  of  that 
nerve.  This  branch  is  known  as  the  great  petrosal  nerve  ;  it  emerges 
from  the  Fallopian  canal  through  the  hiatus  Fallopii,  passes  along  the 


74  ORAL  DISEASES  AND   SURGERY. 

groove  loading  from  this  foramen,  until,  reaching  the  foramen  lace- 
rum  basis  cranii,  it  pierces  the  cartilaginous  substance,  filling  up  this 
osseous  break,  and  entering  the  vidian  canal,  associated  with  the 
carotid  nerve,  passes  forward  under  the  name  of  vidian  to  the  gan- 
glion. The  third,  or  sympathetic,  is  derived  from  the  carotid  plexus 
through  the  vidian. 

The  branches  of  distribution  from  this  ganglion  are  numerous, 
and  supply  a  portion  of  the  orbital  periosteum,  the  nares,  the  hard 
and  soft  palates,  the  half  arches,  the  tonsil,  the  pharynx,  etc. 

The  ascending  branches,  two  or  three  in  number,  enter  the  orbit 
through  the  spheno-maxillary  fissure,  and  supply  the  periosteum. 

The  descending,  called  palatine  branches,  are  three  in  number; 
the  anterior  of  these,  or  large  palatine  nerve,  descends  through  the 
posterior  palatine  canal,  passes  along  the  groove  on  the  hard  palate, 
and  is  distributed  to  the  gums,  the  mucous  membrane,  and  palatine 
glands,  anastomosing  back  of  the  incisor  teeth  with  the  naso-pala- 
tine  nerve  ;  while  in  the  palatine  canal,  filaments  are  given  off  which 
pass  to  the  middle  and  inferior  turbinated  bones. 

The  middle  branch,  called  external  palatine  nerve,  descends  through 
the  same  canal  as  the  preceding ;  it  distributes  its  filaments  to  the 
soft  palate,  to  the  uvula,  and  the  tonsil. 

The  posterior,  called  small  palatine  nerve,  descends  through  the 
accessory  palatine  canal,  and  emerges  back  of  the  posterior  palatine 
foramen.  It  is  distributed  to  the  levator  palati  muscles,  the  soft 
palate,  tonsil,  and  uvula. 

There  are  two  sets  of  branches  coming  off  from  the  internal  sur- 
face ;  these  are  called  superior  nasal  and  naso-palatine. 

The  superior  nasal,  four  or  five  in  number,  enter  the  nasal  fossa  by 
the  spheno-palatine  foramen ;  they  supply  the  mucous  membrane  of 
the  superior  portion  of  the  fossa. 

The  naso-palatine  enters  the  fossa  with  the  other  nasal  nerves, 
passes  across  the  roof  of  the  nose,  until,  reaching  the  septum,  it  de- 
scends between  the  periosteum  and  mucous  membrane  to  the  ante- 
rior palatine  foramen ;  passing  through  this  canal,  it  unites  with  its 
fellow  of  the  opposite  side,  and  distributes  its  filaments  to  the  mu- 
cous membrane  about  the  incisive  fossa. 

Naso-Palaline  Ganglion  or  Ganglion  of  Cloquet. — This  is  simply 
the  small  swelling  situated  in  the  incisive  fossa,  the  result  appar- 
ently of  the  union  of  the  naso-palatine  nerves.  The  very  name  of 
ganglion  is  denied  it  by  most  writers. 

Otic  Ganglion.— This  is  an  oval   flattened  body,  of  small  size, 


THE  FIFTH  PAIR    OF  NERVES.  75 

lying  on  the  sensor  portion  of  the  inferior  maxillary  nerve,  imme- 
diately beneath  the  oval  foramen.  Its  branches  of  communication 
are,  by  sensor  filaments  with  the  auriculo-temporal  nerve,  by  motor 
Avith  the  inferior  maxillary  nerve,  and  with  the  sympathetic  by  the 
plexus  surrounding  the  middle  meningeal  artery.  Branches  of  com- 
munication also  exist  with  the  glosso-pharyngeal,  and  through  the 
medium  of  the  lesser  petrosal  with  the  facial  nerve. 

The  branches  of  distribution  are  two  in  number :  one  to  the  ten- 
sor tympani,  and  one  to  the  tensor  palati  muscles. 

Submaxillary  Ganglion. — This  is  a  small  sized  circular  ganglion, 
situated  upon  the  submaxillary  gland.  It  is  connected,  through 
communicating  branches,  with  the  gustatory  nerve,  sensor ;  with  the 
facial,  through  the  medium  of  the  chorda  tympani,  motor  ;  and  with 
the  sympathetic  by  filaments  from  the  plexus  of  the  nervi  molles. 

The  branches  of  distribution  are  five  or  six  in  number  ;  they  arise 
from  the  lower  part  of  the  ganglion,  and  supply  the  duct  of  the  gland 
and  mucous  membrane  of  the  floor  of  the  mouth. 

FUNCTION   OF   THE   FIFTH   NEKVE.* 

"  The  determination  of  the  functions  of  the  roots  of  spinal  nerves 
has  afforded  the  clew  to  that  of  the  functions  of  the  roots  of  the  fifth 
nerve.  The  analogy  of  the  smaller  root  of  the  fifth  with  the  ante- 
rior spinal  root,  and  of  the  larger  one  with  the  posterior  spinal  root 
has  long  been  admitted  by  anatomists.  Hence  an  analogy  of  func- 
tion must  be  admitted,  and  the  former  must  be  viewed  as  consisting 
of  motor  fibers,  the  latter  of  sensitive  ones ;  and  by  tracing  each  of 
the  three  great  divisions  of  the  nerve,  we  may  determine  its  func- 
tion by  its  constitution,  according  as  it  derives  its  fibers  from  either 
root  or  from  both.  The  ophthalmic  and  superior  maxillary  are  com- 
posed of  fibers  derived  exclusively  from  the  larger  root ;  they  are, 
therefore,  sensitive  nerves.  The  inferior  maxillary  consists  of  fibers 
derived  from  both  roots,  and  consequently  is  both  motor  and  sensi- 
tive. Sir  C.  Bell,  in  his  original  exposition  of  the  functions  of  this 
nerve,  fell  into  error  from  having  neglected  to  avail  himself  of  this 
method  of  analyzing  the  constitution  of  each  of  its  three  divisions, 
from  which  he  would  have  seen  that  it  is  the  inferior  maxillary  alone 
which  derives  its  fibers  from  both  roots,  and  which  perfectly  resem- 
bles a  spinal  nerve  in  constitution. 

*  See  Todd  and  Bowman. 


76  ORAL  DISEASES  AND  SURGERY. 

■  "  The  distribution  of  the  three  divisions  of  the  fifth  nerve  confirms 
most  amply  the  view  of  its  physiology  suggested  by  the  anatomy  of 
its  origin.  The  ophthalmic  and  superior  maxillary  are  distributed 
entirely  to  sentient  surfaces,  or  anastomose  with  motor  nerves  (the 
facial).  They  supply  the  skin  of  the  forehead,  of  the  eyelids,  the 
conjunctiva,  the  eyeball,  the  mucous  membrane  of  the  nostrils,  the 
integuments  of  the  face,  the  upper  lip,  the  nose,  the  beard  on  the 
upper  lip,  the  integument  of  the  ear,  the  temple,  and  the  whiskers  ; 
they  are  the  sensitive  nerves  to  these  regions.  The  inferior  maxil- 
lary has  two  distinct  sets  of  branches — the  one  by  which  the  muscles 
of  mastication  are  supplied ;  the  other,  which  go  to  the  integuments 
of  the  lower  lip  and  chin,  and  the  beard,  and  the  mucous  membrane 
of  the  mouth  and  tongue.  This  nerve  is,  therefore,  the  nerve  of  mas- 
tication, and  of  sensation  to  the  surfaces  above  named. 

"  Repeated  experiments  in  the  hands  of  various  physiologists, 
none  of  which,  however,  were  more  conclusive  than  those  of  Mayo, 
indicate  the  same  views  of  function.  Division  of  the  ophthalmic  or 
of  the  superior  maxillary  induced  loss  of  sensibility  without  muscu- 
lar paralysis,  leaving  only  such  an  impairment  of  the  motor  power 
as  destruction  of  the  sensitive  nerves  invariably  produces,  by  im- 
pairing the  power  of  exact  adjustment,  for  which  a  high  degree  of 
sensibility  is  necessary.  But  when  the  inferior  maxillary  nerve  was 
cut,  then  both  the  power  of  mastication  Avas  destroyed  on  the  same 
side,  and  the  sensibility  of  the  lower  part  of  the  face  and  tongue  was 
lost.  If  the  nerve  were  divided  in  the  cranium,  the  whole  side  of 
the  face  and  forehead,  with  the  eyeball  and  nose,  became  insensible, 
and  the  muscles  of  mastication  were  paralyzed.  Irritants  might 
then  be  applied  to  the  eyeball,  without  exciting  winking,  or  causing 
pain,  and  strong  stimulants  might  be  introduced  into  the  nostrils 
without  creating  the  least  irritation.  When  the  trunk  of  the  nerve 
within  the  cranium  of  an  ass  was  irritated,  the  jaws  closed  with  a 
snap  from  the  excitation  of  the  motor  fibers,  which  are  distributed  to 
the  muscles  of  mastication. 

"  The  conclusions  which  we  draw  from  anatomy  and  from  experi- 
ment are  confirmed  by  the  histories  of  cases  in  which  the  fifth  nerve 
had  been  diseased.  In  such  instances  we  may  observe  the  most 
marked  separation  of  the  motor  and  sensitive  power,  when  the 
larger  portion  only  or  the  two  superior  divisions  of  the  nerve  are 
affected,  and  we  find  both  motion  and  sensation  destroyed  when  the 
whole  trunk  of  the  nerve  is  involved  in  the  disease.  It  is  not 
uncommon  in  such  cases  to  find  the  eyeball  totally  insensible  to 


THE  FIFTH  PAIR    OF  NERVES.  77 

every  kind  of  stimulus,  the  nose  quite  unexcitable  by  the  fumes  of 
ammonia,  or  the  most  pungent  vapors,  and  the  mucous  membrane  of 
the  mouth  so  insensible  to  the  contact  of  foreign  matters  that  a  mor- 
sel of  food  will  sometimes  remain  between  the  gum  and  the  cheek 
until  it  has  become  decomposed.  The  insensibility  of  the  eyeball 
exposes  it  to  the  permanent  contact  of  irritating  particles  of  dust, 
etc.,  which  excite  destructive  inflammation  of  its  textures.  The 
whiskers  may  be  pulled  forcibly  without  sensation.  The  muscles 
of  mastication  become  wasted  and  inert,  as  shown  by  the  distinct 
depression  in  the  regions  of  the  masseter  and  temporal  muscles,  but 
the  superficial  muscles,  on  which  the  play  of  the  features  depends, 
preserve  their  natural  condition. 

"  The  fifth  nerve  may,  therefore,  be  regarded  as  the  motor  nerve 
in  mastication,  and  the  sensitive  nerve  to  that  great  surface,  both 
internal  and  external,  which  belongs  to  the  face  and  anterior  part  of 
the  cranium.  From  its  great  size,  and  the  large  portion  of  the  me- 
dulla oblongata  with  which  it  is  connected,  it  may  excite  other 
nerves  which  are  implanted  in  that  center  near  to  it.  Thus  it  may 
be  an  exciter  to  the  portio  dura,  as  in  winking  ;  or  to  the  respiratory 
nerves,  as  in  dashing  cold  water  in  the  face,  or  in  sneezing.  Its  lin- 
gual portion  distributed  to  the  mucous  membrane  of  the  tongue  is 
at  once  a  nerve  of  taste,  touch,  and  common  sensibility,  and  its  con- 
nection with  the  papillary  structure  of  the  red  parts  of  the  lips  con- 
stitutes it  a  pre-eminently  sensitive  nerve  of  touch  in  those  regions. 

"  The  study  of  the  pathological  conditions  of  this  nerve  illustrates 
its  physiology  in  a  highly  interesting  manner.  In  the  dentition  of 
children,  whether  primary  or  secondary,  it  is  always  affected,  more 
or  less :  and  in  excitable  states  of  the  nervous  centers,  the  irritation 
of  it  consequent  upon  the  pressure  of  the  teeth  often  gives  rise  to 
convulsions,  the  brain  and  spinal  cord  being  irritated  ;  and  we  can 
often  trace  to  such  irritation,  whether  in  infancy  or  in  childhood,  the 
foundation  of  epileptic  seizures  in  subsequent  years.  Painful  affec- 
tions of  the  face  {neuralgia)  have  their  seat  in  this  nerve;  tic  dou- 
loureux, for  example.  Many  of  the  instances  of  painful  affection  of 
this  nerve  or  of  branches  of  it,  which  come  under  our  observation, 
are  well-marked  examples  of  reflected  sensation,  the  primary  irrita- 
tion being  conveyed  to  the  center  by  the  vagus  or  the  sympathetic 
from  the  stomach  or  intestinal  canal.  No  one  of  these  is  so  common 
as  the  pain  over  the  brow,  which  so  often  follows  derangement  of 
stomach  digestion  ;  and  which  may  frequently  be  instantaneously  re- 
moved by  taking  away  the  source  of  irritation,  as  by  neutralizing  free 


78 


OEAL  DISEASES  AND  SURGERY. 


acid  in  the  stomach.  Frequently  also  the  branches  of  this  nerve,  in 
greater  or  less  number,  on  one  or  both  sides,  may,  according  to  the 
humoral  view,  form  a  focus  of  attraction  for  a  morbific  matter  gen- 
erated in  the  blood,  in  persons  exposed  to  the  paludal  poison,  or  in 
persons  of  rheumatic  or  gouty  constitution ;  in  these  cases,  as  in 
most  others  of  similar  pathology,  the  neuralgia  occurs  in  paroxysms 
of  greater  or  less  severity,  each  paroxysm  being  followed  by  a  pe- 
riod of  convalescence,  which  lasts,  it  may  be  supposed,  until  the 
morbid  matter  has  been  again  accumulated  in  quantity  sufficient  to 
induce  a  hiffh  de2:ree  of  irritation  of  the  nerves." 


CHAPTER    IT. 

DENTITION. 

The  direct  and  associative  lesions  of  the  teeth  being  so  common 
and  so  many,  the  study  of  the  diseases  of  the  mouth  will  naturally 
commence  Avith  these  organs. 

In  the  foetus  of  six  weeks  is  to  be  observed,  at  the  border  of  the 
palate,  a  groove  occupying  the  position  of  the  future  teeth.  This 
groove  is  called  the  primitive  dental ;  scattered  along  the  bottom  of 
it  are  certain  fine  papillae,  which,  in  their  development,  are  found 
gradually  to  assume  the  shape  of  the  crowns  of  teeth.  As  these 
papillfe  grow,  the  groove  is  converted  into  a  series  of  distinct  folli- 
cles for  their  accommodation  by  the  growth  of  septi  between  each 
papilla,  which  septi  soon  begin  to  ossify,  to  assist  in  forming  the 
bony  sac  or  alveolus  common  to  the  perfected  teeth.  It  is  seen, 
however,  that  the  septi  complete  only  a  circumferential  boundary, 
the  summit  of  the  papilla  being  exposed.  Before,  however,  the 
papilla  has  assumed  the  form  of  the  tooth,  the  upper  soft  margin  of 
the  pit  enlarges  and  falls  over,  forming  an  operculum  or  lid. 

The  tooth  thus  forming  is  generally  regarded  as  a  cutaneous 
production,  and  would  seem  to  be  a  modification  of  the  hair  or  nail. 
If  such  inference  is  an  error,  and  this  body  is  not  entirely  a  cutaneous 
production,  it  is  plainly  enough  seen  that  the  papillae,  being  sub- 
mucous, enveloped,  or  overlain  by  the  mucous  membrane  lining 
the  primitive  groove,  must,  in  its  development,  either  rupture  this 
envelope,  or  assume  and  modify  it.  Now,  what  is  the  state  of  the 
case  ?  According  to  the  observations  of  Goodsir,  and  the  opinion 
of  Todd  and  Bowman,  "the  tooth  papillae  must  be  regarded  as 
homologous  with,  or  answering  to  the  tactile  and  hair  papillae  of  the 
skin,  and  it  would  therefore  be  expected  that  its  main  part  would 
consist  of  a  peculiar  submucous  tissue,  covered  by  a  homogeneous 
basement  membrane,  and  surmounted  by  a  tissue  answering  to  the 
epithelium.  The  substance  of  the  papillae  is,  at  first,  a  congeries  of 
granular  nuclei,  dispersed  irregularly  through  a  firm,  homogeneous, 
subgranular  matrix  or  blastema,  in  which  vessels  and  nerves  are 

(79) 


80  ORAL  DISEASES  AND   SURGERY. 

by  degrees  developed.  This  is  bounded  by  a  definite  transparent 
membrane,  on  which  rests  a  reflection  of  the  epithelium  lining  the 
sac,  modified  in  structure  so  as  to  present  a  series  of  columnar, 
nucleated  particles,  the  matrix  of  the  future  enamel."  It  would  ap- 
pear, according  to  these  observers,  that  the  lining  and  reflected 
layers  of  the  epithelium  become  blended  together,  and  constitute  but 
one,  Avhich  is  more  adherent  to  the  sac  than  to  the  papilla ;  so  that  on 
opening  the  sac  its  walls  generally  seem  unattached  to  the  surface 
of  the  papilla,  and  the  latter  to  be  limited  to  what  has  been  regarded 
as  the  basement  membrane. 

The  growth  of  the  papilla,  thus  circumstanced,  is  considered  by 
these  authors  as  follows :  "  Between  the  columnar  epithelium  lining 
the  sac  and  the  surface  of  the  alveolar  cavity,  that  is,  apparently  in 
the  wall  of  the  sac  itself,  is  found  a  thick,  semi-transparent,  pulpy 
tissue,  which  has  been  termed  the  enamel  pulp.  It  presents  toward 
the  pulp  of  the  tooth — that  is,  toward  the  original  papilla — a  series 
of  elevations  and  depressions  precisely  the  reverse  of  those  of  the 
dentinal  pulp  on  w^hich  they  rest,  and  answering  mutually  to  these, 
with  only  the  columnar  epithelium  intervening.  The  structure  of 
this  pulpy  tissue  is  elastic,  spongy,  loaded  with  fluid  albumen,  but 
destitute  of  vessels. 

"  In  a  vertical  section  of  these  parts,  the  enamel  pulp  is  seen 
covered  with  columnar  epithelium,  the  enamel  matrix  on  the  surface 
toward  the  dentinal  or  tooth  pulp;  while  on  the  opposite  surface 
the  blood-vessels  of  the  membrane  lining  the  alveolus  are  seen 
coming  up  to  and  forming  loops  immediately  under  the  enamel 
pulp,  without  penetrating  it.  It  is  further  remarkable  that  short 
tubes,  filled  with  glandular  epithelium,  descend  among  these  vessels 
from  the  enamel  pulp,  and  end  by  blind  extremities.  How  these 
tubes,  which  are  evidently  glandular,  can  discbarge  their  contents, 
it  is  difiScult  to  understand,  seeing  they  appear  to  open  into  the  sub-  i 
stance  of  the  enamel  pulp.  J 

"  The  next  stage*  is  that  of  ossification  ;  and  the  earthy  matter  is 
first  deposited  in  the  homogeneous  membrane  forming  the  dentina 
pulp.  The  most  prominent  portions  of  the  crown  are  the  first  t( 
harden  ;  and  the  ossification  proceeds  inward  by  the  gradual  conver 
sion  of  the  pulp  into  the  dentine  or  ivory.  The  nucleated  particles  o 
the  pulp  nearest  the  ossifying  surface  are  found  arranging  themselves 
in  series  vertical  to  that  surface ;  and  it  appears  that,  in  order  t( 

*  Goodsir,  Todd  and  Bowman,  observations  continued. 


DENTITION.  81 

form  these  vertical  series,  they  multiply  by  transverse  division, 
much  as  those  of  bone  cartilage  are  found  to  do.  The  earthy  matters 
are  then  deposited  in  the  indistinct  cells  surrounding  the  nuclei,  so 
as  to  form  the  hard  and  dense  walls  of  the  dentinal  tubes,  as  well 
as  the  intercellular  substance,  so  as  to  form  the  intertubular  tissue  of 
the  perfect  tooth.  The  cells  unite  endwise,  and  their  nuclei  elongate 
and  coalesce  in  a  manner  to  constitute  the  cavities  of  the  tubes,  and 
so  as  often  to  retain  this  mode  of  origin  in  their  permanent  form. 

"  The  calcification  of  the  enamel  commences  on  the  surface  of  the 
dentine  in  contact  with  that  primary  osseous  sheet  formed  from  the 
basement  membrane  of  the  dentinal  pulp.  On  this  primary  layer 
are  minute  shallow  cups,  closely  aggregated,  answering  to  the  ends 
of  the  enamel  columns  and  receiving  them  in  a  firmly  cemented 
union,  as  the  consolidation  of  the  elementary  cells  proceeds.  The 
enamel  columns  at  a  very  early  stage  seem  to  consist  only  of  a  single 
series  of  nucleated  particles,  intervening  between  the  dentine  and 
enamel  pulp.  Those  of  the  new  row  arrange  themselves  endwise 
on  the  others,  which  they  resemble  in  all  respects,  so  that  the  enamel 
attains  its  proper  thickness  rather  by  the  superposition  of  particle  or 
particles  successively  deposited,  and  by  the  subsequent  calcification 
of  each  in  its  turn,  than  by  the  development  of  its  parts  by  an  in- 
terstitial increase ;  and  thus  it  appears  to  differ  from  the  dentinal 
pulp  and  to  resemble  the  epithelium,  to  which  it  is  allied. 

"  It  is  from  that  surface  of  the  enamel  pulp  which  looks  toward 
the  tooth  that  this  successive  development  of  new  enamel  columns 
proceeds ;  as  they  form,  this  tissue  wastes ;  but  it  is  not  probable 
that  the  pulp  is  converted  into  the  columns,  as  the  dentinal  pulp  is 
converted  into  dentine,  because  the  anatomical  characters  of  the 
pulp  are  so  dissimilar  from  those  of  the  columns.  When  first  calci- 
fied, the  enamel  rods  are  loosely  aggregated,  and  easily  separate 
from  one  another  under  pressure  ;  but  they  gradually  become  so 
consolidated  by  the  advance  of  the  calcifying  process  in  their  inter- 
stices, as  to  make  the  finished  enamel  the  most  hard  and  inde- 
structible of  all  the  products  of  organization. 

"The  development  of  the  layer  containing  the  ordinary  lucunae 
of  bone,  and  which  in  the  human  teeth  covers  the  fang,  and  is  con- 
tinued a  little  way  within  the  cavity  of  the  root,  does  not  seem  to 
have  been  as  accurately  studied  as  that  of  the  dentine  and  enamel. 
There  can  be  little  doubt  that  a  membranous  matrix,  probably  like 
that  of  the  cranial  bones,  is  laid  down  as  the  fang  is  developed, 
in  which  the  usual  steps  of  ossification  precede  the  lacuuse  and 

6 


82  ORAL  DISEASES  AND  SURGERY. 

their  canaliculi,  being  formed  from  the  corpuscles  of  the  temporary 
matrix. 

"  When  the  ossification  of  the  dentine  is  so  far  advanced  that  the 
tooth  can  sustain  with  impunity  the  pressure  to  which  it  is  destined, 
and  when  the  enamel  is  densely  calcified,  the  eruptive  stage  occurs, 
in  which  the  tooth  makes  its  way  through  the  gum.  This  is  due 
to  the  same  law  of  development  which  governs  the  form  and  position 
of  other  organs.  The  gum  over  the  sac  is  absorbed,  and  the  crown 
of  the  tooth  is  forced  upward  against  it,  chiefly  by  the  increasing 
size  of  the  fang  below. 

"  As  the  development  of  the  teeth  proceeds,  so  does  that  of  the 
alveoli :  so  that  by  the  time  the  teeth  break  through  the  gums,  their 
walls  are  sufficiently  strong,  and  embrace  the  necks  of  the  teeth  with 
firmness  enough  to  furnish  a  solid  basis  of  support.  Their  vascular 
canals  are  developed,  and  especially  those  which  convey  to  each 
tooth  its  interior  supply  of  vessels  and  nerves.  The  gums  and 
alveoli  are  likewise  provided  with  vessels  which  play  their  part  in 
the  development  and  subsequent  nutrition  of  the  organs." 

These  are  the  views  of  development  entertained  by  the  authors 
above  quoted.  Investigations  which  I  myself  have  made  in  the 
direction  have  seemed  to  simplify  the  matter  very  much,  and,  in- 
deed, to  deprive  it  of  a  very  great  share  of  its  obscurity.  Whether 
these  views  may  be  nearer  right  than  the  various  others  held,  the 
reader  may  for  himself  determine. 

At  a  certain  period  of  foetal  life  a  groove  is  observed,  the  pro- 
gressive development  of  which  proves  it  to  be  the  primitive  dental 
groove.  This  groove  is  lined  by  a  delicate  membrane  continuous 
with  the  mucous  membrane,  and  perhaps  a  part  of  it — modified,  but 
still  a  part  of  it,  just  as  the  conjunctival  cells  which  pass  over  the 
cornea  are  really  part  and  parcel  of  the  common  ocular  conjunctiva. 
This  membrane,  at  points  corresponding  with  the  position  of  future 
teeth,  is  elevated  into  papillae  or  little  hills.  A  section  through  the 
membrane,  over  any  of  the  bulbs,  exposes  a  papilla.  This  papilla 
or  body,  closely  examined,  is  found  to  be  made  up  of  a  congeries  of 
granular  nuclei,  dispersed  irregularly  through  a  firm  homogeneous 
blastema.  This  papilla  is  the  rudiment  of  the  future  tooth,  as  obser- 
vation of  its  development  proves.  It  is  not  inclosed  in  a  cell  wall  or 
membrane  of  its  own,  but  is  a  kind  of  hyaloid  structure  or  substance. 
The  papilla,  thus  understood,  is  seen  to  lie  beneath  the  mucous 
membrane ;  and  in  this  membrane  resides  a  certain  amount  of  elas- 
ticity.    As  the  papilla  enlarges  and  projects  itself,  it  becomes  in- 


DENTITION.  83 

closed  to  all  the  extent  possible  with  this  mucous  membrane  con- 
tracted about  the  body  so  as  to  constitute  a  sac  or  cell  wall,  just 
precisely  as  the  parietal  peritoneum  contracts  about  and  makes  a  sac 
to  the  projected  intestine  in  hernia.  This  sac  enveloping  the  papilla 
has  its  continuation,  as  is  seen,  necessarily  over  the  sides  of  the 
groove ;  as  then  this  groove  enlarges  and  deepens,  and  finally  en- 
velops the  papilla,  it  is  seen  that  the  body  or  tooth  germ  gets  a 
second  sac.  It  is  as  though  one  should  envelop  his  head  in  a 
double  night-cap,  and  then  bind  over  this  a  handkerchief — the  sub- 
mucous structure  of  the  lateral  walls  and  operculum  representing 
the  handkerchief. 

At  this  period,  the  pulp  or  original  papilla  having  attained  the 
size  of  the  tooth  it  represents,  commences  the  process  of  the  forma- 
tion of  dentine.  Before  the  attainment  to  full  size  of  the  papilla, 
there  existed  between  it  and  its  sac  proper  a  halitus  or  fluid.  This 
halitus,  now  that  the  congeries  of  cytoblasts  or  nucleated  granules 
have  obtained  their  full  growth  and  secretive  power,  is  replaced  by  a 
more  highly  endowed  secretion,  the  work  of  these  matured  cells. 
This  secretion,  deposited  against  the  inner  sac,  or  between  it  and 
the  pulp,  contains  the  elements  of  the  dentinal  structure,  is,  indeed, 
the  dentine,  and  deposits  layer  after  layer,  supported  by  and  moulded 
into  form  by  the  sac. 

As  this  deposit  intrudes  on  the  pulp,  so  this  body  contracts  within 
itself,  until,  finally,  by  some  law  of  nature,  it  stops  at  that  certain 
point  which  maintains  within  the  tooth  a  canal  or  cavity,  and  a 
vascular  and  nervous  pulp  to  occupy  it, — this  pulp  being  the  con- 
tracted original  papilla ;  the  vessels  of  this  papilla  being  vessels 
entirely  analogous  to  any  one  of  the  ordinary  papilla  of  touch,  so 
supplied  and  so  maintained. 

Why  this  secretion,  in  its  organization,  should  assume  the  position 
of  the  elongated  tubular  cells  which  pertains  to  the  structure  of 
dentine,  1  have  of  course  no  idea,  and  it  is  quite  enough  for  our 
purpose  to  say  that  it  is  a  law  of  life  perhaps  never  to  be  compre- 
hended this  side  of  eternity,  and  the  discovery  of  which  would,  at 
any  rate,  have  but  little  practical  signification  to  us. 

The  formation  of  the  dentine  completed,  the  covering  of  it  with 
enamel  begins,  or  rather  this  deposit  is,  to  a  degree,  coincident 
with  the  dentinal  formation.  Secreted  by  the  same  pulp  which 
formed  the  dentine,  the  same  secretion,  some  portion  of  it  finds  its 
way  into  and  through  the  primary  sac.  As  it  passes  through  this 
sac  it  is  modified,  receives  new  elements,  perhaps,  which,  as  it  is 


84  ORAL   DISEASES  AND   SURGERY. 

received  into  the  second  space,  or  the  space  between  the  first  and 
second  caps,  and  its  calcification  commences,  impresses  upon  it  the 
arrangement  of  its  particles  after  the  hexagonal  order  of  the  enamel. 
Between  the  enamel  thus  formed  and  the  dentine  exists  the  primary 
sac;  simply  the  originally  modified  mucous  membrane,  which  we 
first  saw  as  overlying  the  papilla.  This  membrane  continues  its 
existence  between  these  two  hard  bodies,  and  receives  and  modi- 
fies, for  the  support  of  the  enamel,  the  liquor  sanguinis  sucked  out 
from  the  dentinal  tubules  and  intertubular  structure.  It  may  be 
called  the  enamel  membrane.  It  has  of  course  been  much  modified, 
and  it  is  from  it  that  we  receive  the  impressions  of  pain  when  it  is 
exposed  by  a  break  in  the  continuity  of  enamel. 

The  growth  of  the  root  of  the  tooth,  as  its  dentine  is  concerned, 
has  precisely  the  history  of  the  body.  It  is  associated  with  the 
pyramidal  elongation  of  the  papilla  or  pulp,  which,  pushing  up- 
ward the  crown,  elongates  upon  itself  the  enamel  membrane.  This 
elongation,  with  a  greater  vascularity  and  vitality  assumed  by  the 
membrane  as  it  approaches  the  basement  vessels,  modifies  again  the 
result  obtained  by  the  secretion  passing  through  it  from  the  dentinal 
pulp,  the  result  being  a  nearer  approach  to  true  bone  in  the  produc- 
tion of  cementum.  The  periodonteum  is  simply  the  modified  external 
sac,  lost  of  course  above  the  neck  as  the  tooth  has  emerged  through  it. 

This  is  a  very  simple  and  easily  understood  explanation  of  tooth 
growth.  The  observations  leading  to  the  conclusions  were  some- 
what extensive,  and,  to  my  mind,  the  phenomena  are  indorsed  by 
general  physiological  analog)^ 

We  may  pass  here  to  what  infinitely  more  concerns  us  as  prac- 
titioners— namely,  the  relations  of  the  first  and  second  dentitions. 

The  teeth  are  divided  into  two  sets  or  dentitions.  The  first  is 
called  the  deciduous,  milk  or  temporary,  and  consists  of  twenty 
teeth, — ten  to  each  jaw.  The  second  is  called  the  permanent  set, 
and  consists  of  thirty-two  teeth, — sixteen  to  each  jaw.  These 
various  teeth,  in  size,  density,  and  general  character,  are  relative 
to  the  jaws  containing  them.  The  first  set  consists  of  eight  incisors, 
four  canines,  and  eight  molars.  The  second  set  consists  of  eight 
incisors,  four  canines,  eight  premolars,  and  twelve  molars. 

Of  the  first  set,  the  papillae  of  the  anterior  molar  appear  first,  the 
canine  and  incisors  next,  and  the  posterior  molars  last.  About  the 
fourth  month  these  papillae  are  all  in  their  sacular  envelopes,  and 
forming  behind  the  lids  of  the  sacs  are  little  crescentic  depressions, 
called  cavities  of  reserve,  lined  with  mucous  membrane,  and  con- 


DENTITION.  85 

taining  the  germs  of  the  papillae  of  the  second  set  of  teeth, — one  to 
each  deciduous  germ.  The  first  molar  of  the  permanent  set  is 
markedly  related  to  the  deciduous  set,  by  having  a  common  origin 
from  and  in  the  primitive  dental  groove ;  and  from  sacs,  secondary 
to  the  capsule  of  this  tooth,  spring  the  reserve  cavities  of  the  second 
and  third  molars  of  the  second  set. 

The  eruption  of  the  temporary  set,  although  more  or  less  irregular, 
ensues,  as  a  rule,  in  the  following  order  and  time :  the  lower  teeth 
erupt  first — the  four  central  incisors  about  the  seventh  month,  the 
lateral  incisors  about  the  eighth  month,  the  anterior  molars  about 
the  thirteenth  month,  the  canines  about  the  sixteenth  month,  and  the 
posterior  molars  about  the  twenty-fourth  month.  The  period  inter- 
vening between  the  first  and  last  eruption  is  considered  the  critical 
period  in  infantile  existence.  (See  chapter  on  Associated  Lesions  of 
First  Dentition.) 

The  ossification  of  the  permanent  teeth  commences,  just  before 
birth,  with  the  anterior  molars,  proceeding  forward,  but  terminating 
with  the  premolar  at  about  the  third  year ;  the  posterior  molars  are 
the  last  to  ossify. 

The  position  of  the  permanent  papillae,  which  at  first  are  situated 
between  the  sacs  of  the  deciduous  and  the  gum,  gradually  recedes 
behind,  falling  deeper  and  deeper,  at  least,  relatively  so,  as  the 
milk  set  elongates,  until,  on  the  completion  of  growth  in  the  decidu- 
ous, the  germs  of  the  permanent  set  are  found  in  a  common  alveolus 
at  the  apices  of  these  cavities,  occupying,  indeed,  almost  the  position 
and  physiological  relations  of  the  original  papillae. 

At  this  point,  whenever  it  may  be,  and  it  varies  of  course  with 
different  individuals,  commences  a  process  of  antagonism, — it  is 
intended  that  the  new  shall  advance  and  increase,  that  the  old  shall 
decline  and  diminish.  The  relative  position  of  the  two  bodies  is  as 
follows :  extending  to  the  apices  of  the  alveoli,  and  receiving  at  these 
apices  the  principal  vessels  of  nutrition,  are  the  perfected  roots  of 
the  first  teeth.  Crowding  down  into  these  alveoli,  with  nutritious 
vessels  of  their  own,  possessed  with  the  high  vitality  of  growing 
bodies,  are  the  pulps  of  the  second  teeth, — it  is  the  story  repeated  of 
the  rootlet  lifting  the  stone.  As  these  pulps  enlarge,  so  is  there  a 
corresponding  enlargement  in  the  alveoli  containing  them,  until, 
finally,  through  such  process  of  absorption  they  have  fallen  directly 
beneath  the  roots  of  the  first  set.  Of  course  a  pressure  has  been 
equally  exerted  upon  these  roots,  and,  as  a  result,  the  nutritious 
vessels  passing  into  the  pulp  cavities,  through  the  foramina  at  the 


86 


ORAL   DISEASES  AND  SURGERY 


apices,  have  been  gradually  obliterated.  But  do  the  pulps  of  the 
milk  teeth  die?  Not  at  all;  or  at  least  not  necessarily.  The  neigh- 
boring vascularity  is  very  great,  the  requirements  of  the  organ  very 
small ;  a  sufficient  supply  is  received  from  the  circulation  in  the 
dentine,  as  well  as  from  the  periosteum,  which,  to  the  last,  con- 
tinues to  close  in  the  enlarging  foramina.  But  this  does  occur :  the 
absorbent  or  destructive  system  has  been  given  the  mastery,  and 
little  by  little,  day  by  day,  and  month  by  month,  the  roots  of  the 
first  teeth  disappear,  while  the  crowns  of  the  second  advance,  and 
occupy  the  space  gained,  until  at  length,  as  is  witnessed  every  day, 
the  milk  tooth  drops  out  of  the  cavity,  minus  a  root,  while  the  crown 
of  the  permanent  is  seen  in  its  cavity. 

If  here  we  take  up  this  thrown  off  tooth,  we  shall  find  that  the 
pulp  chamber,  or  what  remains  of  it,  instead  of  having  an  almost 
complete  bony  envelope,  as  is  the  case  in  the  perfect  organ,  has 
communicated  more  and  more  largely,  for  a  varying  period,  with 
the  soft  parts,  guarding  us,  in  such  knowledge,  against  a  treat- 
ment in  aching  milk  teeth,  at  certain  periods,  which  would  be  most 
applicable  at  others. 


Fig.  33.  —  General  Appearance  of  the  First  Set  ok  Milk  Teeth. 

1.  2.  3.  4.  5. 


6.  7.  8.  9. 

Temporary  teeth  of  one  side.  1,  2,  upper  and  lower  incisors  ;  3,  upper  and  lower 
canine  ;  4,  5,  upper  and  lower  molars  ;  6,  7,  triturating  surface  of  the  lower  molars  ;  8,  9, 
triturating  Burfaco  of  the  upper  molars. 


To  judge  of  the  condition  of  the  foramina  of  the  first  teeth,  we 
compare  them  with  periods  of  eruption  of  the  second,  recognizing 
that  the  enlargement  or  absorption  corresponds  with  such  advance  in 
the  permanent. 


DENTITION.  87 

The  first  teeth  of  the  second  set  erupt  entirely  back  of  the  tem- 
porary, and  in  no  way  interfei'e  with  them.  These  are  the  anterior 
or  first  molars,  and  appear  commonly  at  about  the  sixth  year, 
seldom  earlier,  but  not  unfrequently  from  one  to  several  months 
later;  the  sixth  year,  however,  is  the  rule.  The  second  teeth  to 
appear  are  the  central  incisors,  the  lower  a  little  in  advance  of 
the  upper — about  the  seventh  year ;  the  third,  the  lateral  incisors, 
at  the  eighth  year  ;  the  fourth,  the  anterior  premolars,  at  the  ninth 
year ;  the  fifth,  the  posterior  premolars,  at  the  tenth  year ;  the  sixth, 
the  canine  or  cuspidati,  at  the  eleventh  year ;  the  seventh,  the 
second  molars,  at  the  twelfth  year;  and  the  last,  the  third  molars  or 
wisdom  teeth,  at  a  period  varying  from  the  seventeenth  to  the  twenty- 
fifth  year — more  commonly,  however,  about  the  eighteenth  year. 


CHAPTER    V. 

ASSOCIATIVE   LESIONS   OF    FIRST   DENTITION.  I 

Although  it  comes  not  strictly  within  the  province  of  a  work  on 
surgery  to  treat  of  the  associative  lesions  of  the  first  dentition,  yet 
it  would  seem  that  such  a  work  could  not  be  at  all  complete  without, 
at  least,  reasonable  reference  to  such  conditions.  1 

When  one  considers  the  delicate  and  susceptible  organism  of  an 
infant  human  being,  and  the  fact  of  its  usherance  into  a  world  where 
active  causes  of  disease  are  in  constant  antagonism  to  it,  he  is  very  I 
well  i)repared  to  understand  that  in  the  influences  of  the  process  of 
dentition  must  necessarily  exist  a  powerful  predisposing  cause  in- 
viting to  attack,  and,  indeed,  opening  the  portals,  as  it  Avere,  to 
enemies  that  otherwise  might  have  passed  harmlessly  by. 

The  calculations  of  Dr.  Arbuthnot  that,  at  this  period,  one  in 
every  ten  children  has  its  life  destroyed  through  the  associative 
and  influenced  lesions  of  the  age,  may,  perhaps,  not  be  strictly  in 
accordance  with  statistics  at  large ;  but  the  mortality  is  so  alarm- 
ingly great  that,  to  the  general  practitioner,  no  subject  offers  in  its 
study  more  important  and  vital  interests. 

In  the  first  place,  we  have  to  remark  that  the  process  of  dentition, 
while  a  physiological  one,  is  yet,  like  that  of  utero-gestation,  one  of 
continuous  irritation.  Of  the  meaning  of  this  word  irritation,  every 
surgeon  and  every  physician  has  in  his  mind  full  quite  enough  1 
reminiscences.  Irritation,  then,  is  the  matter  of  consideration  in  all  * 
and  every  of  these  associative  lesions ;  if  happily,  in  such  cases,  we 
could  exactly  appreciate  and  exactly  control  such  irritations,  we 
should  of  course  abort  or  resolve  the  results. 

It  is  not,  however,  by  any  means  to  be  esteemed  that  all  infantile 
diseases  are  influenced  by,  or  indeed  even  remotely  associated  with, 
dentition :  mistakes  of  such  nature  are  quite  too  frequently  made, 
and  infants  are  tortured,  and  iu  many  cases  have  the  existing  dis- 
ease aggravated,  by  the  lancing  and  cutting  which  follow.  It  is 
very  true  that  irritation  from  this  cause  has  not  always  an  associ- 
ated external  local  manifestation;  but  such  manifestation  is,  I  think, 
(88) 


ASSOCIATIVE  LESIONS   OF  FIRST  DENTITION.      89 

much  more  frequently  to  be  found  present  than  absent, — at  any  rate, 
it  should  always  have  its  full  share  in  the  diagnosis.  It  will  of  course 
be  taken  for  granted  that  dental  irritation  is  influenced  to  a  most 
marked  extent,  all  things  being  equal,  by  the  slowness  or  rapidity 
of  the  evolution  of  the  teeth.  Thus,  such  equality  existing,  we  would 
not  anticipate  from  the  eruption  of  a  single  tooth  the  trouble  of  five 
or  six,  and  such  a  difference  in  evolution  is  so  marked  that  it  may  be 
said  of  some  children  that  they  cut  their  teeth  in  mass,  while  with 
others  it  is  a  process  of  the  greatest  regularity  and  harmony. 
Again,  the  physical  condition  and  age  of  the  child  are  matters  not 
without  much  significance.  A  delicate  infant  suffers  more,  as  a  gen- 
eral thing,  than  a  robust  one,  while  premature  dentitions  are  attended 
with  more  danger  than  late  ones.  In  taking  into  consideration  the 
influences  of  this  process,  we  are  not  to  forget  either  the  varying 
degrees  of  susceptibility,  as  manifested  in  different  individuals,  as 
thus  we  are  led  to  appreciate  the  fact  that  judgment  is  not  to  be 
founded  alone  upon  the  extent  or  degree  of  local  manifestation.  Some 
children  are  preternaturally  susceptible  to  stimuli,  and  these  are 
not  at  all  necessarily  of  the  weak  and  feeble  class  ;  others,  on  the 
contrary,  are  so  obtuse,  even  from  earliest  age,  as  to  be  very  little 
influenced  by  any  ordinary  or  common  cause  of  irritation. 

To  the  experienced  physician,  the  appreciation  of  associated  or 
abstract  dental  irritation  should  not  be  a  matter  of  difficulty.  He  sees 
and  he  does  what  is  to  be  done,  what  only  can  be  done ;  if  the  treatment 
fails,  the  fault  resides  not  in  the  practice.  In  the  first  place,  to  under- 
stand dental  irritation,  one  must  be  familiar  with  dental  evolution; 
this  of  course  is  the  understanding  of  the  physiology  of  the  subject. 
We  know  the  varying  periods  of  eruption,  and  we  are  thus  at  once 
led  very  dii'ect  in  our  researches.  If  we  find  a  source  of  offense,  as 
manifested  by  a  tumid,  congested  gum,  we  have  only  to  pass  a  lancet 
down  to  the  confined  tooth,  and  having  done  this,  we  may  expect 
and  hope  for  relief  from  any  general  trouble  which  has  been  en- 
gendered by  the  just  liberated  organ.  If  we  look  into  the  mouth, 
and  see  no  manifestations  of  offense,  it  is  generally  the  case  that 
dentition  has  nothing  to  do  with  a  trouble  which  may  have  in- 
fluenced the  search,  —  not  always,  however,  for  I  have  inferred 
that  dentition  may  be  a  source  of  reflected  trouble,  while  itself  pre- 
senting no  local  signs.  Still,  such  cases  are  very  rare,  and  when 
existing  depend  on  great  rapidity  in  evolution,  either  as  a  single 
tooth  is  concerned  or  the  simultaneous  advancement  of  a  number. 
Many  teeth,  rapidly  advancing  at  the  same  time,  could  very  well 


90  ORAL  DISEASES  AND  SURGERY. 

be  esteemed  as  a  source  of  constitutional  offense,  not  only  as  di- 
verting in  such  direction  an  excess  of  the  vital  force,  but  also  in 
local  irritations  induced  in  neighboring  structures,  and  which  might 
not  at  all  be  evident  by  any  external  signs.  In  these  latter  cases, 
the  physician  can  do  nothing  but  increase,  by  indicated  means,  the 
ability  of  the  system  to  endure  the  irritation ;  such  means  being 
more  frequently  found  in  tonics  than  in  sedatives.  In  the  weak, 
strict  attention  is  to  be  given  to  diet,  to  exercise,  and  cleanliness. 
The  character  of  the  clothing  is  also  of  much  consequence.  If  the 
milk  of  the  mother  is  not  properly  nutritious,  other  means  are  to  be 
taken  to  nourish  the  child. 

In  cases  where  there  seems  simply  an  excess  of  irritability,  such 
susceptibility  is  to  be  lowered  by  the  withdrawal  of  any  and  every- 
thing capable  of  fostering  it;  this  will  pertain  to  the  lodgment  of 
the  child,  food,  drink,  clothing,  exercise,  etc.,  matters  which  would 
at  once  strike  the  observing  practitioner. 

Disturbance  provoked  in  the  alimentary  canal,  and  fever  induced 
through  the  process  of  teething,  when  existing  conjointly  with  acute 
disease,  of  whatever  character,  necessarily  aggravate  such  disease, 
and  increase  by  just  that  much  the  attending  discomfort  or  danger; 
hence  the  recognized  increased  mortality  in  the  exanthemata  occur- 
ring at  this  period. 

The  diseases,  if  they  may  be  so  called,  directly  associated  with 
and  dependent  on  abnormal  dentition,  and  having  therefore  neces- 
sarily their  cure  more  or  less  intimately  associated  with  the  correc- 
tion of  the  primary  lesion,  are — 

1st.  Localized  Stomatitis. 

2d.  Irritative  Fever. 

3d.  Diarrhoea. 

4:th.  Spasms. 

5th.  Eruptions  on  the  Skin,  especially  the  Scalp  and  Face. 

1.  Localized  Stomatitis. — The  first  indication  in  this  condition, 
dependent  on  advancing  tooth  eruption,  consists,  most  likeh',  in  a 
sense  of  titillation  or  itching, — as,  before  any  local  sign  is  visible, 
the  child  is  found  irritating  the  parts  with  anything  coming  into  its 
hands,  seeming  most  comfortable  when  biting  upon  hard  substances. 
Slavering  is  also  associated  with  this  stage.  After  a  time  tume- 
faction of  the  gums  is  observed,  and  this  inflammatory  action  circum- 
scribes or  extends  itself  on  the  same  principle  as  the  vaccine  disease 
— that  is,  as  influenced  by  constitutional  or  local  circumstances.  If 
several  teeth  are  attempting  eruption  at  the  same  time,  and  these 


ASSOCIATIVE  LESIONS   OF  FIRST  DENTITION.      91 

are  situated  at  opposite  sides  of  the  cavity,  then  the  probability  is 
that  the  inflammation  will  be  a  diffused  one.  If,  on  the  contrary, 
the  irritation  is  confined  to  a  single  tooth,  and  there  is  in  the  habits 
of  the  child  no  particular  inflammatory  tendency,  then  it  may  reason- 
ably be  anticipated  that  the  area  of  congestion  will  be  very  circum- 
scribed. The  shape  and  extent  of  face  in  the  erupting  tooth  have 
not  seemed  to  me  to  have  as  much  to  do  with  the  amount  of  irrita- 
tion as  one  would  naturally  infer  to  be  the  case.  I  have  certainly 
seen  quite  as  much  trouble  from  an  erupting  incisor  as  in  the  case 
of  a  four-cusped  molar.  Bad  and  degenerating  inflammations  are 
always  associated  with  constitutional  conditions.  Thus  in  scrofulous 
children,  it  is  sometimes  the  case  that  a  semi-gangrenous  ulceration 
is  the  result  of  cutting  a  tooth  which  it  is  quite  troublesome  enough 
to  manage ;  while  in  children  of  a  syphilitic  cachexia  such  a  condi- 
tion will  be  even  aggravated,  the  gums  and  continuity  of  mucous 
membrane  looking  as  if  it  was  impossible  to  keep  the  parts  from 
breaking  down  into  general  ulceration.  When  tumefaction  of  the 
gum  is  dependent  on  tooth  eruption,  and  the  child  is  of  healthy  con- 
dition, a  certain  evidence  is  found  in  the  glistening  character  of  the 
swelling :  the  part  immediately  over  the  tooth  or  teeth  looks  stretched 
and  feverish.  This  tense  look  is  nearly  always  present,  and  may, 
under  all  circumstances,  be  esteemed  an  indication  demanding  the 
use  of  the  lancet.  In  unhealthy  conditions,  this  glistening  is  not 
commonly  present,  its  absence  being  dependent  on  the  flaccid,  re- 
laxed condition  of  the  gum  tissue.  Here,  as  implied,  the  congestion 
is  of  more  diffused  character;  the  part  and  associate  parts  are  turgid 
and  soft  looking.  You  esteem,  in  looking  into  the  mouth,  that  scari- 
fication would  be  of  service,  but  that  it  is  demanded  for  a  sense  of 
general  relief,  rather  than  for  a  strictly  acute  local  condition.  Lanc- 
ing in  the  first  of  these  cases,  if  properly  performed,  yields  an  almost 
instantaneously  good  result ;  in  the  second,  such  relief  is  gradual, 
and  most  likely  inconsiderable.  In  the  first,  it  is  all-sufficient  to  the 
cure ;  in  the  second,  the  constitutional  indications  are  soon  felt  to  be 
of  much  more  consequence  than  any  local  requirements. 

To  lance  the  gums  of  a  child,  let  the  surgeon  seat  himself  directly 
in  front  of  the  nurse,  the  height  of  the  knees  of  the  two  parties  cor- 
responding. Let  the  nurse  now  take  the  child  on  her  lap,  support- 
ing its  whole  body,  excepting  the  shoulders  and  head,  which  are  to 
rest  upon  the  knees  of  the  operator.  In  this  position  the  nurse  con- 
trols perfectly  the  legs  and  arms  of  the  infant,  while  the  surgeon  has 
complete  command  of  its  head,  and  can  examine  and  operate  upon 


92  ORAL  DISEASES  AND  SURGERY. 

its  mouth  at  his  convenience.  The  face  of  the  child  should  look 
toward  the  window,  or  if  night  is  the  time  of  operation,  a  candle  or 
lamp  will  be  found  all-sufficient. 

A  tooth  should  be  lanced  in  consideration  of  its  shape.  Thus,  if 
it  be  any  of  the  anterior  six  teeth,  either  of  the  upper  or  lower  jaw, 
a  single  incision  made  sufficiently  deep  to  feel  the  lancet  strike  upon 
the  enamel  is  all  that  is  required.  This  incision  should  be  made 
across  the  mouth,  or  on  the  line  of  the  cutting  edge  of  these  teeth,  as 
we  find  them  in  our  own  mouth.  With  the  posterior  teeth,  the 
crucial  form  of  incision  is  demanded:  such  form  will  alone  relieve  the 
advancing  cusps,  and  affords  the  result  desired. 

Concerning  hemorrhage,  it  has  not  been  my  experience  that  any 
special  danger  is  to  be  apprehended.  I  certainly  never  hesitated  to 
lance  the  gums  of  a  child  on  this  score,  and  never  met  with  a  case 
that  gave  me  any  particular  trouble.  In  ordinary  cases,  the  loss  of 
a  little  blood  is  rather  to  be  desired  than  otherwise,  while  if  a  hemor- 
rhagic diathesis  exists,  the  local  application  of  strong  alum-water  or 
of  bayberry  powder  will  generally  be  found  all-sufficient  for  its  con- 
trol. A  little  cobweb,  as  found  in  the  cellar,  wet  with  borax-water, 
and  then  dipped  in  the  bayberry  powder,  will  in  ninety  cases  out  of 
the  hundred  not  fail  to  control  the  bleeding,  when  laid  over  the  in- 
cision,— the  application  to  be  secured  by  passing  over  it,  if  necessary, 
one  layer  of  a  delicate  roller. 

A  constitutional  medicament,  of  great  effect  in  these  cases,  will  be 
found  in  the  Erigeron  Canadense.  One  drop  of  the  tincture  to  be 
given  in  a  little  water,  each  minute,  until  the  bleeding  ceases,  or 
until  twenty  or  thirty  drops  are  taken.  Opium  and  lead  act  very 
happily  in  combination.  The  dose  of  each  must  of  course  be  small. 
A  very  good  formula  would  be  as  follows: 

B. — Pulv.  opii,  gr.  :^; 
Plumbi  acet.  gr.  i; 
Aqua,  giij.     M. 
Sig.  Teaspoonful  to  be  taken  each  half  hour,  p.  r.  n. 

Touching  a  bleeding  gum  with  Monsel's  solutions,  or  with  ni- 
trate of  silver,  is,  in  my  experience,  dangerous  practice.  The  only 
alarming  cases  of  hemorrhages  I  have  ever  seen  have  been  the  re- 
sults of  such  applications.  It  is  true  that  such  effects  may  rest 
rather  with  the  operator  than  with  the  agents  ;  but  it  is  seldom 
that  one  seems  to  succeed  in  using  them  with  sufficient  cleverness 
and  localization.      They  are  certainly  much  more  apt  to  do  a  great 


ASSOCIATIVE  LESIONS   OF  FIRST  DENTITION.      93 

deal  of  harm  than  any  reliable  good  ;  secondary  hemorrhages  are 
common  to  them,  and  which  are  always  of  a  character  much  more 
difficult  to  manage  than  the  primary  trouble. 

Another  matter  in  this  connection  particularly  worthy  of  note,  is 
the  influence  on  the  hemorrhage  through  the  sucking  propensity  of 
the  child.  This  is  to  be  obviated  by  passing  a,  roll  of  rubber  or 
other  convenient  material  across  the  mouth,  and  so  confining  it  as 
while  it  shall  not  fret  the  little  patient,  it  will  destroy  the  ability  to 
make  a  vacuum  This  manipulation  is  very  simple  and  easy  of 
accomplishment.  The  ordinary  soft  india-rubber  ring  may  be  cut 
in  the  middle;  tie  a  piece  of  string  or  tape  to  either  end,  pass  the 
rubber  across  the  mouth,  and  fix  the  tapes  on  the  back  of  the  neck ; 
an  hour  or  two  will  be  found  quite  sufficient  to  retain  the  apparatus 
in  the  mouth. 

Cases  of  localized  stomatitis,  having  association  with  the  strumous, 
scorbutic,  or  syphilitic  cachexia,  require,  as  suggested,  a  treatment 
external  to  the  cause  exciting  it;  the  child  must  be  built  up;  the  in- 
flammation passing  quickly  into  an  adynamic  type  demands  for  its 
cure  stimulation  rather  than  depression ;  or,  to  express  the  require- 
ments more  justly  and  explicitly,  a  local  treatment  must  be  quieting 
and  perhaps  refrigerating,  while  tonics,  combined  with  the  mineral 
acids,  will  be  required  constitutionally. 

A  child  eight  years  of  age,  of  marked  scrofulous  condition,  tissues 
relaxed,  abdomen  pendant,  was  presented  at  one  of  my  clinics,  suf- 
fering with  trouble  in  the  oral  cavity.  Making  an  examination,  the 
mucous  membrane  of  the  palatine  aspect  of  the  superior  jaw  was 
found  angry  and  uncomfortable  looking,  no  tension  at  any  point,  but 
the  whole  membrane  turgid,  and  yet  flaccid  looking.  In  searching 
for  the  cause  of  trouble,  the  age  of  the  patient  directed  a  first  atten- 
tion to  the  position  of  the  first  bicuspid  teeth,  the  lateral  incisors 
being  erupted  and  in  position ;  exploration  with  the  lancet — the 
deciduous  molars  had  been  removed  long  before — revealed  these 
teeth  on  either  side,  with  the  second  bicuspid  of  the  right  side 
nearly  ready  to  erupt.  The  ordinary  crucial  incisions  were  then 
made.  In  the  case  of  a  healthy  child,  this  would  have  been  all- 
sufficient;  with  such  a  child,  however,  not  so.  Eelief  from  the 
incision  will  certainly,  to  some  extent,  be  obtained;  but  the  conges- 
tion will  continue,  and  it  may  be  will  grow  worse,  the  parts  seem- 
ing to  lack  that  energy  necessary  to  the  restoration.  In  this  par- 
ticular case,  and  which  is  here  noted  merely  as  a  type,  the  mouth 
was  ordered  to  be  washed  three  times  each  day  with  very  dilute 


94  ORAL  DISEASES  AND  SURGERY. 

brandy  and  aromatic  sulphuric  acid.  Internally,  lemonade  was  given 
each  two  hours,  five  drops  of  brandy  to  each  wineglassful.  Aro- 
matic sulphuric  acid  acts  very  happily  in  these  and  similar  cases, 
or  the  nitromuriatic  acid  may  be  administered  in  from  two-  to  five- 
drop  doses,  three  or  four  times  a  day.  Iron,  combined  with  an  acid, 
as  in  the  Tinctura  Ferri  Chloridi,  is  a  most  admirable  medicine,  given 
in  from  five-  to  eight-drop  doses,  three  times  a  day.  It  is  found 
also  not  unfrequently  necessary  in  these  cases  to  bring  the  acid,  in  a 
more  concentrated  form,  directly  to  bear  upon  some  obstinate  point 
of  ulceration ;  this  is  done  very  readily  by  means  of  a  pine  stick. 
Dip  the  point  into  the  acid  u.sed,  and  employ  concentrated  or  dilute 
according  to  the  seeming  requirements  of  the  case.  The  acid  nitrate 
of  mercury  so  applied  is  found  sometimes  to  act  very  happily,  or  the 
deliquesced  chloride  of  zinc  may  be  used.  The  zinc,  followed  by  a 
brush  of  the  ofiicinal  tincture  of  iodine,  will  sometimes  induce  granu- 
lation as  if  by  magic ;  or  the  iodine  combined  with  creasote  may  be 
employed  with  every  hope  of  success. 

In  syphilitic  stomatitis,  specific  treatment  must  be  conjoined  with 
the  supporting.  A  combination  that  I  use  with  the  most  satisfactory 
effect  is  as  follows : 

B. — Hydrarg.  bichl.  gr.  1 ; 
Potass,  iod.  5i ; 

Sj-rupus  ferri  pyrophos.  ^iv.     M. 
Sig.  From  a  quarter  to  half  teaspoonful,  according  to  age,  three 
times  a  day. 

It  not  unfrequently  happens,  however,  that  a  treatment  which  has 
preceded  ours  has  been  too  free  in  the  exhibition  of  the  mercurials; 
here  the  medicine  is  not  to  be  longer  used,  but,  conjoined  with  the 
supporting  treatment,  we  are  to  employ  the  chlorate  of  potash. 

R. — Potassae  chloras,  ^ss  ; 
Aqua,  Iviii.     M. 
S.  Teaspoonful,  internally,  four  to  six  times  a  day,  and  the  mouth 
to  be  washed  with  the  same,  ad  libitum. 

In  all  adynamic  conditions  of  childhood,  it  is,  I  presume,  a  com- 
mon experience  that  no  better  treatment  is  to  be  found  than  lies 
in  the  observance  of  general  hygienic  laws.  The  food  must  be 
nourishing,  and  not  given  to  repletion.  Fresh  air  and  exercise  are 
necessities.     The  child  should  sleep  by  itself,  or,  what,  as  it  is  con- 


ASSOCIATIVE  LESION^S   OF  FIRST  DENTITION.      95 

cerned,  is  even  better,  it  might  sleep  with  some  young  person  of 
more  robust  and  healthy  condition.  The  daily  use  of  the  salt-sheet 
bath,  with  the  water  tepid  or  cold,  according  to  the  ability  of  the 
patient  to  bear.  This  is  an  invaluable  adjunct  to  restoration.  Throw 
the  wet  sheet  quickly  about  the  person  of  the  child,  and  rub  until  a 
fine  glowing  reaction  sets  in.  In  the  use  of  this  means,  however, 
close  attention  is  to  be  given  to  the  daily  result.  If  reaction  is  not 
secured,  but  the  child  seems  cold,  and  the  cutaneous  capillaries  con- 
tract, then  such  bath  is  to  be  discontinued ;  or  if  the  cold  water  has 
been  used,  it  must  be  modified,  even  perhaps  to  absolute  warmness. 
A  good  plan  to  adopt  with  this  bath,  is  to  commence  with  milk- 
warm  water,  and  advance  with  gradations  to  cold. 

All  the  functions  of  a  child  of  scrofulous  or  syphilitic  condition 
are  to  be  carefully  attended  to.  If  the  bowels  are  habitually  cos- 
tive, as  is  very  frequently  the  case,  olive  oil  of  good  quality  may 
be  administered  q.  s.  This  oil  not  only  obviates  such  a  condition, 
but  acts  as  a  most  desirable  article  of  nutrition.  If  given  alone,  a 
teaspoonful  or  dessertspoonful,  each  day,  administered  at  any  con- 
venient period,  -will  generally  be  found  sufficient, — and,  indeed,  in 
many  cases,  too  laxative.  If  the  child  is  of  an  age  to  take  the  oil 
mixed  with  other  food,  much  attention  to  the  quantity  employed 
will  not  be  found  of  special  consequence.  In  cases  where  the 
kidneys  fail  to  eliminate  with  sufficient  rapidity,  small  doses  of 
sweet  spirits  of  nitre  may  be  exhibited.  Buchu,  where  there  is 
undue  irritability  of  the  urinary  apparatus,  will  be  found  to  apply 
very  happily.  A  prescription  which  I  very  frequently  make,  is  as 
follows : 

R. — Take  of  buchu  one  ounce ;  add  one  and  one-half  pints  of  hot 
water,  and  simmer  down  to  one  pint;  when  cold,  strain,  and  give  in 
teaspoonful  doses,  four  or  six  times  a  day,  p.  r.  n. 

Particular  attention  is  also  demanded  to  the  state  of  the  skin.  It 
should  feel  soft,  not  relaxed,  moist,  and  reasonably  oily ;  it  must  be 
kept  very  clean,  but  not  washed  too  frequently  with  soap.  Whisky 
or  brandy,  where  stimulation  seems  indicated,  may  be  added  to  the 
water  with  which  a  child  is  bathed  ;  but  a  healthy  skin  is  to  be  made 
rather  from  within  outward,  than  from  without  inward — that  is  to 
say,  a  skin  which  does  not  perform  properly  its  offices,  indicates,  as 
a  general  thing,  some  derangement  ulterior  to  itself,  so  that  the  local 
attention  implied  is  never  to  be  esteemed  but  as  adjunct  treatment. 
It  has  not  unfrequently  happened  to  me  to  observe  that  a  stomatitis, 
having  apparently  a  local  signification,  has  immediately  disappeared 


96  ORAL  DISEASES  AND  SURGERY. 

upon  the  correction  of  a  trouble  existing  in  the  skin.     This  is  mark- 
edly seen  in  the  retrograde  exanthems. 

Angina  simplex,  a  simple  inflammation  of  the  fauces,  is  not  un- 
frequently  dependent  on  irritations  existing  or  having  origin  in  the 
oral  cavity.  Here  the  trouble  is  simply  one  of  continuity,  and  its 
cure  is  found  of  course  in  the  cure  of  the  oral  trouble.  Angina 
simplex,  or  the  extension  of  the  oral  inflammation,  is  generally  first 
made  evident  in  difficulty  of  swallowing.  Examination  reveals  the 
throat  red  and  engorged,  the  degree  being  influenced  by  the  con- 
dition of  the  patient.  Sometimes  this  congestion  is  so  great  as  to 
make  the  act  of  deglutition  an  impossibility ;  even  fluids  taken  into 
the  throat  will  be  ejected  through  the  nostrils.  The  uvula  oc- 
casionally will  be  enlarged  to  an  extent,  as  the  result  of  effusion  into 
its  cellular  structure,  which  seriously  endangers  the  respiration  of 
the  patient,  compelling,  indeed,  in  many  cases,  the  amputation  of 
the  organ.  In  some  instances  aphthous  patches  appear  upon  various 
parts  of  the  mucous  membrane ;  these  denote  that  the  inflammation 
is  adynamic  in  its  type,  and  are,  I  think,  always  a  matter  for  con- 
cern, just,  indeed,  as  a  phagedenic  chancre  is  a  cause  for  more  alarm 
than  a  simple  sore,  implying  absence  of  vital  force  and  degenerative 
tendency.  An  aphthous  ulcer  is  a  patch  of  yellow  exudate,  frequently 
excavated,  but  not  necessarily  so.  It  is  the  form  of  ulceration  and 
exudation  so  frequently  seen  in  weakly,  broken-down  women.  The 
microscope  exhibits  the  aphthous  exudate  as  a  fungous  growth ;  it 
has,  however,  as  yet  failed  in  designating  its  specific.  Angina  sim- 
plex, it  has  been  remarked,  when  dependent  on  any  oral  trouble, 
may  be  expected  to  retire  upon  the  removal  of  the  immediate  cause. 
This,  however,  is  not  always  the  case,  as  witnessed  in  the  ady- 
namic types,  or  in  children  of  very  full  or  sanguine  temperaments. 
In  these  cases,  a  treatment  must  be  pursued  as  implied  in  the  indi- 
cations. If  the  continuance  of  the  inflammation  depends  upon  the 
surcharged  conditions  of  the  vessels,  a  general  or  local  depletion 
will  be  found  demanded.  Three  or  four  Swedish,  or  twice  as  many 
American  leeches,  may  be  put  upon  the  upper  part  of  the  neck ;  the 
number  to  be  graduated  to  the  strength  of  the  patient  and  the 
urgency  of  the  case.  A  treatment  preliminary  to  this,  and  one 
which  in  my  own  practice  I  always  employ,  when  the  case  is  not 
especially  urgent,  consists  in  reducing  the  volume  of  blood,  either 
by  the  administration  of  diaphoretics  or  the  saline  cathartics. 
Epsom  salts,  a  tcaspoonful  in  a  wineglass  of  water,  will  carry 
much  fluid  from  the  blood  of  a  young  child;  or  the  spirits  of  Min- 


ASSOCIATIVE  LESIONS   OF  FIRST  DENTITION.     97 

dererus — covering  the  patient  warmly  until  diaphoresis  is  produced 
— given  in  teaspoonful  doses,  every  ten  minutes,  will  be  found  to 
sometimes  very  quickly  break  up  such  inflammations  Hot  pedi- 
luvia  are  not  to  be  neglected ;  the  feet  and  legs  of  the  little  patient, 
kept  in  hot  water  for  the  space  of  a  quarter  of  an  hour,  will,  in  very 
many  cases,  be  all-sufficient  for  a  cure.  A  less  speedy,  but  fre- 
quently very  successful  way  of  treating  angina,  consists  in  divert- 
ing, as  it  were,  the  seat  of  irritation;  thus,  by  the  administration  of 
nitre  we  may  send  it  to  the  kidneys,  or  with  tarter  emetic  we  can 
throw  it  upon  the  skin. 

B. — Spts.  ammoniae  aromat. 
Spts.  seth.  nit.  aa  ^ss.     M. 
S.  Give  from  five  drops  to  a  teaspoonful,  according  to  age,  every 
three  or  four  hours. 

The  ammonia  in  the  above  prescription  drives  the  congested 
blood  forward,  while  the  nitre  directs  it  toward  the  kidneys. 

In  cases  in  which  the  circulation  is  deficient  in  the  cutaneous 
capillaries,  as  indicated  by  their  diminished  caliber,  small  doses  of 
antimony  answer  an  admirable  end.  This  treatment  may  be  con- 
joined with  one  of  the  salts  of  morphia,  or  the  two  together  may 
be  given  in  the  Hoffmann's  anodyne  mixture. 

An  emetic  will  not  unfrequently  break  up  a  sthenic  sore  throat. 
In  the  case  of  children  syrup  of  ipecacuanha  answers  every  purpose. 
It  may  be  given  in  doses  varying  from  a  half  to  a  full  teaspoonful, 
according  to  age,  every  ten  or  fifteen  minutes,  until  the  desired 
result  of  emesis  is  obtained. 

If,  conjoined  with  the  local  inflammation,  we  have  a  sympathizing 
by  the  system  at  large,  as  manifested  in  fever,  febrifuges  are  to  be 
employed.  The  following  combination  will  be  found  happily  adapted 
to  such  indications: 

R. — Liq.  potassEe  citrat.  §iij  ; 
Spts,  seth.  nit.  ^ss  ; 
Ant.  et  potass,  tart. 
Morph.  acet.  aa  gr.  i.     M. 

Of  this  mixture  the  dose  for  an  adult  would  be  a  dessertspoonful 
every  two  hours ;  for  an  infant,  one  year  of  age,  from  five  to  eight 
drops  might  be  given,  being  diminished  or  increased  according  to 
effect.     Overdoses  produce  sick  stomach. 

1 


08  ORAL  DISEASES  AND  SURGERY. 

l)[et. This  should  of  course  be  light,  as  in  all  sthenic  inflamma- 
tions. The  child  may  be  limited  to  the  breast  alone ;  or  if  age  or 
circumstances  will  not  permit  of  this,  gum-water,  or  other  light  and 
unstimulating  food,  should  be  alone  employed  —  that  is  to  say, 
should  be  alone  employed  while  the  grade  of  the  inflammation  is 
running  upward.  Ice-cream  is  an  admirable  food,  particularly  when 
eaten  slowly,  and,  I  may  say,  continuously.  By  continuously,  how- 
ever, I  do  not  mean  that  great  quantities  are  to  be  taken,  but  a 
reasonable  portion  be  made  to  last  as  long  as  possible.  Eaten  in 
this  way,  it  is  refrigerant  not  only  to  the  inflamed  part  over  which 
it  necessarily  passes,  but  to  the  system  at  large,  lowering  the  heat 
of  the  whole  body,  and  thus  quieting  the  disturbed  circulation. 

Chronic  Angina. — Inflammation  of  the  fauces,  running  into  a 
chronic  condition  in  children,  may  perhaps  always  be  esteemed  as 
depending  on  some  constitutional  predisposition.  In  these  cases 
the  glandular  bodies  seem  to  be  mo.st  markedly  the  seat  of  trouble. 
Granulations  are  generally  prominent  over  the  mucous  membrane, 
this  tissue  being  covered  with  a  mucoid  or  muco-purulent  secretion. 
Ulcers  are  very  common,  and  not  unfrequently  are  of  such  degener- 
ative tendency  as  to  threaten  the  continuity  of  the  parts.  A  dis- 
agreeable association,  connected  nearly  always  with  a  neglected 
angina,  is  the  chronic  enlargement  of  the  tonsil  glands.  I  have 
been  compelled  to  operate  in  these  cases,  as  every  slight  cold  would 
so  swell  up  these  bodies  as  to  render  respiration  almost  as  difficult 
as  in  asthma.  I  have  just  now  under  treatment  a  little  girl,  in 
whom,  from  this  cause,  these  glands  are  so  enlarged  that  respiration 
during  sleep  is  accomplished  only  by  an  effort  that  it  is  absolutely 
painful  to  listen  to.  Of  course  the  case  is  curable  by  excision  ; 
but  to  this  neither  parent  nor  child  can  be  brought  to  submit.  The 
sense  of  tickling  and  rawness  in  the  throat,  in  chronic  angina,  is 
another  source  of  discomfort ;  the  patient  is  constantly  kept  cough- 
ing and  hawking.  This  is  induced  not  unfrequently  through  the 
dryness  of  the  membrane,  and  again  as  a  result  of  the  irritating 
nature  of  the  secretions,  or  it  may  be  dependent  on  ulceration.  From 
whatever  cause  induced,  however,  I  have  never  found  anything 
better  adapted  to  its  temporary  relief  than  gum  arable  held  in  the 
mouth  and  allowed  slowly  to  dissolve.  Difficulty  in  hearing  is 
another  frequent  association  of  chronic  angina, — the  explanation 
being  found  in  the  inflammatory  thickening  of  the  Eustachian  tube. 
Pain  in  the  act  of  swallowing  is  the  result  of  a  lymph  exudate 
n   the   submucous   cellular  tissue.     This   it   is   which    e-ives   the 


ASSOCIATIVE  LESIONS   OF  FIRST  DENTITION.     99 

irregular  thickening  so  observable  about  the  posterior  wall  of  the 
pharynx. 

Chronic  angina,  if  not  dependent  on  any  specific  constitutional 
conditions,  would  be  most  rationally  treated  by  stimulation,  local  or 
general,  or  both,  as  would  seem  to  be  indicated.  The  ordinary 
domestic  remedy  of  a  red-pepper  gargle,  if  judiciously  used,  would 
not  unfrequently  produce  a  speedy  cure.  Unhappily,  however, 
domestic  medication  is  too  apt  to  be  carried  to  excess,  and  thus  adds 
to,  in  place  of  subverting,  a  disease.  If  a  true,  uncomplicated  chronic 
angina  presents  in  a  child,  and  it  will  not  do  to  deny  but  what  such 
cases  may  exist,  let  the  patient  first  be  treated  with  a  wash  com- 
pounded as  follows : 

B. — Tinct.  capsicum  comp.  5ss; 
Aqua,  iviij.     M. 

If  a  few  applications  of  this  gargle  should  not  effect  a  change,  let 
nitrate  of  silver  be  added,  in  proportion  of  one-half  a  grain  to  the 
ounce.  If  even  this  should  not  result  in  the  desired  change,  then  it 
will  be  well  to  esteem  that  a  general  medication  is  indicated.  First 
we  may  set  about  to  correct  any  functional  disturbances  that  may 
be  present,  and  follow  such  corrections  with  tonics.  Muriated 
tincture  of  iron  is  an  admirable  medicine,  where  the  system  seems 
to  require  building  up;  quinine,  in  the  majority  of  cases,  may  be 
given  in  addition,  with  a  very  happy  effect. 

R. — Tinct.  ferri  chl.  Jiij ; 

Quinias  sulph.  gr.  x.     M. 
S.  To  be  taken  in  from  three-  to  ten-drop  doses,  three  times  a 
day. 

Where  treatment,  as  just  indicated,  shall  fail,  alterative  medica- 
ments of  the  various  classes  may  be  tried, — alum-water,  tinct. 
iodinii,  weak  dilutions  of  creasote,  acid  nitrate  of  mercury,  chloride 
of  zinc,  solutions  of  lead,  etc.  Constitutional  vices  must  receive 
full  share  of  attention.  I  have  presumed  to  imply  that  in  children 
affected  with  chronic  angina  the  cause  is  always  found  to  exist  in 
this  direction.  Scrofula  is  by  far  the  most  common  of  these  vices. 
A  scrofulous  child  is  liable  to  almost  any  description  of  physical  de- 
generation. Now  scrofulous  degeneration  is  rather  a  difficult  thing 
to  describe,  the  conditions  are  so  diversified  and  varied.  A  child 
descended  from  consumptive  parents  is  degenerate, — it  is  not  amiss 
to  say  scrofulous.     A  scrofulous  child  has  not  necessarily  a  special 


100  ORAL  DISEASES  AND  SURGERY. 

distinctive  type.  It  may,  for  example,  have  white,  delicate  skin, 
tumid  abdomen,  non-compact,  pouting  lip,  and  the  languid,  listless 
gait.  It  may  have  every  belonging  of  the  most  marked  lymphatic 
temperament ;  or,  on  the  other  hand,  a  scrofulous  patient  may  look 
as  if  possessed  of  all  the  characters  of  a  vigorous  constitution.  I 
do  not  know  what  l)etter  to  do,  in  cases  of  this  kind,  than  to  make 
a  general  observation  of  antecedent  and  present  conditions,  and 
found  a  treatment  accordingly.  Syphilis,  it  has  been  inferred  by 
some  writers,  lies  closely,  or  away  back  in  the  distance,  as  the  root 
of  such  conditions  ;  but  if  such  should  be  the  case,  a  treatment  anti- 
syphilitic  is  not  necessarily  implied.  This  peculiar  vice  may  have 
lost  itself  in  a  general  degenerative  condition,  just  as  an  injury, 
which  has  of  itself  gotten  well,  may  yet  be  the  cause  of  broken 
health  and  physical  adversity,— just,  indeed,  as  phthisis  may  suc- 
ceed syphilis,  long  since  inferred  to  have  been  cured.  In  all  such 
cases  we  can  only  hope,  in  the  correction  of  ill  conditions  recognized 
as  existing,  to  find  the  good  we  require.  We  may  philosophize  and 
reason,  but  if  nothing  functionally  wrong  is  perceived,  we  must 
have  recourse  to  a  somewhat  empirical  treatment,  building,  as  we 
say,  the  patient  up.  In  other  words,  there  are  no  specific  means  of 
cure;  therefore  we  resort  to  such  general  tonics  as  experience  has 
demonstrated  to  be  useful.  Cod-liver  oil,  administered  daily,  cream, 
mixtures  of  spermaceti  and  milk,  preparations  of  iron,  infusions  or 
tinctures  of  the  bitter  barks,  as  the  Peruvian,  serpentaria,  etc.,  are 
medicines  to  be  employed  in  these  cases. 

2.  Irritative  Fever. — Irritative  fever,  or  fever  from  the  irritation 
of  teething,  is  a  direction  of  infantile  trouble  very  frequently  de- 
manding the  attention  of  the  physician.  It  may  not  be  amiss,  for 
the  benefit  of  the  student,  to  remark  that  by  irritative  fever  we 
mean  fever  the  result  of  something  that  produces  overexcitement. 
This,  it  is  true,  would  also  be  a  definition  of  inflammatory  fever, 
the  two  conditions  being  really  one  and  the  same,  except  in  degree. 
Now  the  irritative  fever  of  dentition  is,  as  a  rule,  a  rapid  fever — that 
is,  it  appears  and  disappears  quickly,  the  lancing  of  a  gum  causing 
it  very  frequently  almost  instantly  to  vanish:  not  always,  however, 
for  it  can  readily  be  understood  that  such  a  disturbance  of  the  func- 
tional conditions  could  be  excited  as  to  make  a  return  to  an  equilib- 
rium much  less  probable  than  production  of  some  organic  change. 

All  febrile  conditions  in  children  of  a  sthenic  type  are  attended 
with  much  restlessness ;  but  the  fever  of  dentition  is  markedly  so. 
Muscular  excitability  is  a  prominent  association ;  the  sleep  is  broken ; 


ASSOCIATIVE  LESIONS   OP  FIRST  DENTITION.     101 

thirst  is  very  great;  appetite  impaired  and  irregular,  the  child  taking 
the  breast  rather  for  the  relief  obtained  from  the  moisture  of  the 
milk  than  from  desire  for  food ;  the  pulse  is  not  unfrequently  driven 
to  an  incredible  rapidity;  the  face  is  flushed  and  burning;  the  eyes 
congested  and  protruded.  Convulsions,  and  not  unfrequently  death, 
mark  the  climax. 

The  disturbance  effected  in  the  sj^stem,  as  has  been  remarked, 
will  be  found,  most  likely,  in  proportion  to  the  local  irritation,  and 
the  age,  constitution,  and  general  condition  of  the  patient.  The 
marked  mobility  existing  in  the  nervous  structure  of  infants  renders 
the  brain  peculiarly  susceptible ;  it  is  therefore  a  most  common 
association  to  find  the  feverish  infant  flighty,  and  perhaps  entirely 
out  of  its  head ;  while  if  febrile  disturbance,  consequent  upon  denti- 
tion, supervenes,  when  other  diseases  are  in  progress,  such  diseases 
will  be  commonly  much  intensified. 

The  diagnosis  of  dental  irritative  fever  is  not  always  an  easy 
matter,  and  simply  because  the  fever  is  irritative,  and  not  inva- 
riably inflammatory — that  is  to  say,  the  local  disturbance  is  con- 
fined to  the  nervous  structures,  and  does  not  involve,  to  a  perceptible 
extent,  the  local  vascular.  We  look  into  the  mouth,  but  we  see  no 
swelling  of  the  gums,  no  evidences  of  inflammation;  yet  the  trouble 
is  there,  and  it  may  be  that  it  is  only  by  incision  that  the  fever  is 
to  be  controlled;  the  diagnosis  must  therefore  necessarily  not  unfre- 
quently be  of  a  differential  character,  or  by  exclusion.  To  aid  us 
in  this,  we  not  only  consider  the  absence  of  other  causes  of  irrita- 
tion, but  we  have  a  marked  assistance  in  our  knowledge  of  the 
varying  periods  of  tooth  eruption,  and  of  the  causes  advancing  or 
retarding  such  evolution. 

Where  dental  evolution  is  inferred  to  be  the  cause  of  a  febrile 
manifestation,  and  incisions  do  not  seem  demanded,  we  are  to 
resort  to  ordinary  general  treatment.  Lemonade,  made  with  pounded 
ice,  is  a  most  grateful  and  refrigerating  febrifuge ;  the  neutral  mix- 
ture, made  fresh,  by  simply  adding  the  carbonate  or  bicarbonate  of 
potassa  to  lemon-juice,  is  another  excellent  medicine.  This  addition 
may  be  made  to  a  full  saturation. 

Or  a  refrigerating  mixture,  made  as  follows,  may  be  prescribed, 
and  administered  pro  re  nata  in  teaspoonful  doses : 
R. — Liq.  potassae  citrat.  siij  ; 
Spts.  seth.  nit.  ^ss  ; 
Ant.  et  potass,  tart. 
Morph.  acet.  aa  gr.  \.     M. 


102  ORAL  DISEASES  AND  SURGERY. 

Much  relief  is  given  b}^  sponging  the  skin  when  it  is  very  hot, 
using  water  and  alcohol,  or  water  and  cologne,  or  water  and  vine- 
gar. Bathing  the  wrists  in  cold  water  is  another  source  of  great 
comfort.  Bromide  of  potassium  is  an  admirable  preparation  to 
administer  in  febrile  conditions.  To  children  it  may  be  given, 
dissolved  in  strong,  ice-cold  lemonade,  in  doses  of  two  grains  or 
more  to  the  tcaspoonful. 

Tartar  emetic,  added  to  these  doses  in  the  proportion  of  the  for- 
tieth of  a  grain  to  each,  assists  its  quieting  influence.  Where  the 
pulse  is  much  excited,  and  the  infant  is  of  sthenic  condition,  tinct. 
of  verat.  viride  may  also  be  added,  one  drop  to  each  dose ;  in  the 
use  of  this  last  agent,  however,  the  effect  is  to  be  watched  with 
care.  Emetics  are  highly  valued  by  some.  Cathartics  may  also 
be  used  to  good  purpose,  the  sulphate  or  carbonate  of  magnesia 
being  employed,  as  preferred. 

"When,  in  defiance  of  treatment,  a  fever  of  irritation  continues,  our 
efiForts  are  to  be  directed  to  effects  that  may  be  produced  outside  of 
the  ordinary  functional  disturbances.  The  extension  of  inflammation 
by  continuity,  where,  for  example,  severe  and  unyielding  inflamma- 
tion resulting  from  dentition  exists,  may  produce  pharyngitis,  paro- 
titis, bronchitis,  pneumonitis,  gastritis,  or  it  may  excite  to  take 
an  morbid  action  the  brain,  the  heart,  the  liver,  or,  indeed,  any 
organ  of  the  body.  When  such  sequela  occur,  we  are  to  treat  the 
parts  involved  as  in  any  common  inflammation,  just,  indeed,  as  we 
have  been  treating  the  unyielding  fever,  except  that  we  may  feel 
the  necessity  to  make  such  treatment  more  vigorous ;  it  may  be 
that  under  such  circumstances  we  will  find  the  local  or  general 
abstraction  of  blood  an  absolute  necessity,  while  derivation,  by 
counter-irritation,  will  commend  itself  as  all-important. 

In  these  cases  it  is  not  to  be  forgotten,  however,  by  the  prac- 
titioner, that,  conjoined  Avith  the  original  cause  of  inflammation, 
some  other  may  exist ;  thus,  a  malarial  influence  may  have  been 
lying  in  abeyance,  and  needed  but  the  depression,  the  result  of  the 
dental  trouble,  to  allow  of  its  asserting  itself;  or  some  half-corrected 
tendency  to  congestion  is,  by  the  excitation,  entirely  undone.  Such 
associations  are  constantly  to  be  considered  if  treatment  is  to  be  suc- 
cessful. This  excitation  of  morbid  action  is  well  demonstrated  in 
the  association,  with  dentition,  of  diarrhoea  and  the  cutaneous  erup- 
tions ;  while  the  treatment,  wherever  the  secondary  irritation  shall 
exhibit  itself,  is  recognized  to  have  a  common  character. 

3.  Diarrhoea. — The   alimentary   mucous   membrane   being  con- 


ASSOCIATIVE  LESIONS   OF  FIRST  DENTITION.     103 

tinuoiis  from  the  mouth  to  the  anus,  it  will  be  at  once  recognized 
that  a  localized  inflammation  could  render  irritable  the  whole  tract. 
It  is  thus  that  diarrhoea,  or,  indeed,  more  commonly  all  the  symp- 
toms of  cholera  infantum,  associate  wnth  difficult  tooth  eruption,  and 
it  is  thus  that  to  cure  a  diarrhoea  or  an  attack  of  cholera  infantum 
we  have  so  frequently  only  to  cut  down  upon  a  certain  confined 
tooth  or  teeth.  I  am  led,  however,  to  infer  that  it  is  quite  too 
common  a  practice,  during  the  period  of  dentition,  to  ascribe  to  this 
process  not  only  every  diarrhoea,  but  the  numberless  other  functional 
irregularities  which  may  happen  to  occur  at  such  period.  Diar- 
rhoea, or  this  combined  with  vomiting,  has  many  causes  external  to 
the  influences  of  tooth  eruption. 

The  stomach  of  an  infant  may  be  likened  to  an  enlarged  portion 
of  a  common  tube,  and  not  only  this,  but  it  is  a  vertical  or  almost 
vertical  tube ;  hence  a  child  overfed  needs  only  to  be  inverted  to 
have  the  milk  run  from  the  orifice  of  the  tube. 

Again,  the  mucous  membrane  of  the  intestines  of  an  infant  is 
tender  and  susceptible ;  excess  of  food,  or  food  not  easy  of  digestion, 
irritates  this  membrane,  and,  by  the  relationship  of  tissue,  excites  to 
action  the  middle  coat  of  the  tube,  yielding  discharge  or  diarrhoea. 
Crapulous  diarrhoea  may  thus  be  somewhat  continuous,  for  the  rea- 
son that,  unassisted,  the  contractions  may  fail  to  relieve  the  canal 
of  the  source  of  offense,  and  thus  their  continued  efforts  keep  up 
the  continued  discharges.  Worms  irritating  the  canal  are  not  the 
infrequent  cause  of  diarrhoea.  In  hot  weather  we  generally  have 
an  increase  in  diarrhoea  cases ;  and  not  only  is  the  irritation  thus 
induced  not  limited  to  the  intestinal  tract  proper,  but  the  liver  as 
markedly  sympathizes ;  hence  the  frequency  in  these  months  of 
cholera  infantum,  the  excess  of  bile  being  thrown  both  ways.  En- 
teritis, from  follicular  ulceration  in  typhoid  conditions,  may  induce 
and  keep  up  a  diarrhoea  in  a  child  as  it  does  in  an  adult.  Tabes 
mesenterica  is  a  cause  of  diarrhoea  in  the  scrofulous  infant.  Syphilis 
may  ulcerate  and  irritate  the  intestinal  tract,  just  as  we  so  frequently 
see  such  irritation  in  the  mouth.  These  allusions  are  sufficient  to 
remind  us  that  diarrhoea  is  not  a  disease  but  only  a  symptom,  and 
that,  whether  occurring  in  the  dentitional  or  any  other  period,  it 
may  have,  as  its  provocative,  a  great  variety  of  sources  or  lesions. 
When  a  diarrhoea  depends  on  a  dental  origin  it  is,  perhaps,  always 
a  condition  of  vascular  perversion,  and  is  entirely  direct  in  its 
nature ;  the  erupting  tooth  or  teeth  inflames  the  mucous  membrane 
of  the  mouth,  and,  by  the  continuity  of  tissue,  the  irritability  ex- 


104  ORAL   DISEASES  AXD  SURGERY. 

pends  itself  over  the  intestinal  portion  of  the  structure.  It  is  well 
to  say  that  in  diarrhoea  of  this  character  there  is  much  or  little 
mucin,  according  to  the  state  of  the  inflammation,  and  much  casting 
off  of  epithelial  scales  ;  but  there  is,  of  course,  nothing  diagnostic 
in  such  phenomena,  because  of  not  being  peculiar  to  a  particular 
form  or  character  of  inflammation.  We  are  to  look  at  the  mouth, 
and  we  are  to  look  at  the  throat ;  if  there  is  a  local  condition  of 
irritation  and  inflammation,  and  if  the  vascular  derangement  ex- 
tends as  far  as  we  can  follow  it,  we  have  reasonable  grounds  for 
inferring  that  in  the  teeth  resides  the  origin  of  the  trouble,  particu- 
larly if,  having  examined  the  system  at  large,  we  fail  in  discovering 
other  lesions.  I  desire  not,  however,  to  be  understood  as  asserting 
that  it  is  only  in  this  way  we  have  dental  diarrhoea,  for  I  too  well 
know  there  is  another  way,  and  that  is  through  the  second  of  the 
legs  of  Bichat's  tripod.  I  very  well  know  that  there  is  an  influ- 
enced innervation,  and  that  if  the  bowels  of  an  infant  are  weaker 
than  its  lungs  or  its  brain,  that  deranged  innervation  will  there  ex- 
pend itself  I  have  seen  the  diarrhoea  of  such  deranged  innervation 
relieved  almost  instantly  by  an  incision  into  a  tooth-cyst,  and  yet 
there  was  no  redness,  no  swelling,  or  other  evidences  of  local  ex- 
citability. These  cases  are,  however,  rare,  and  have  their  analogues 
in  the  reflex  spinal  irritations.  The  diagnosis  must  necessarily  be 
somewhat  differential  in  character  ;  yet,  where  a  case  is  at  all  ob- 
scure and  the  circumstances  urgent,  it  is  commendable  practice  to 
make  incisions  over  the  positions  of  teeth  whose  periods  of  eruption 
correspond  most  nearly  with  the  time  of  operation. 

It  is  very  well,  however,  and  indeed  necessary,  to  remember  that 
a  mucous  membrane  may  be  inflamed,  in  varying  localities,  without 
having  intermediate  sanguineous  disturbance.  Thus  a  stomatitis 
and  an  enteritis  might  be  present  at  the  same  moment ;  the  one  de- 
pending on  local  dental  disturbance,  the  other  upon  a  cause  or 
causes  of  entirely  dissimilar  nature.  Now  in  a  case  of  this  kind, 
having  associative  diarrhoea,  it  will  plainly  enough  be  seen  that 
any  treatment  directed  to  the  stomatitis  would  not  (except  as  a 
similarity  in  practice  might  pertain  to  both  troubles)  affect  the 
enteritis.  To  recognize  these  cases,  antecedent  conditions  must  be 
inquired  into.  Colds  or  atmospheric  vicissitudes  will,  most  fre- 
quently perhaps,  be  found  an  explanation  of  the  disturbances.  The 
cutaneous  circulation,  as  a  result  of  some  inadvised  exposure,  has 
been  depressed,  and  thus  the  enteritis  has  been  forced  upon  a  part 
having  the  least  ability  to  resist  the  inrolling  wave.     In  some  in- 


ASSOCIATIVE  LESIONS   OF  FIRST  DENTITION.     105 

fants,  restless  and  nervous  in  their  natures,  a  predisposition  to  enteric 
irritation  or  inflammation  seems  to  be  inborn ;  the  slightest  disturb- 
ance reacts  in  this  way.  It  may  not  be  that  diarrhoea  is  the  result, 
but  the  irritation  exhibits  itself  in  some  evident  way. 

The  milk  of  a  nurse  is  occasionally  the  source  of  a  diarrhoea. 
Infusoria  and  crystalline  substances  will  be  found  frequently,  on  ex- 
amination, in  such  milk.  Here  a  cure  would  only  be  obtained  by  a 
change  from  such  diet  to  one  which  would  be  healthy  or  normal, — 
good  cow's  milk,  diluted  or  pure,  according  to  the  age  of  the  infant, 
being  the  best  substitute.  Other  causes  of  diarrhoea,  to  be  con- 
sidered in  connection  with  a  supposed  but  doubtful  dental  source, 
are  debility;  hepatic  derangements,  interfering  with  the  venous  cir- 
culation ;  an  increased  peristaltic  motion  through  mental  emotions, 
as  anger  or  fright;  a  rheumatic  or  scrofulous  diathesis;  malarial 
influence,  etc. 

Diarrhoea  from  dental  irritation,  if  inflammatory  by  the  continuity 
of  relationship  in  the  membrane,  generally  demands  the  lancet  alone 
for  its  cure;  the  operator  should  free  the  advancing  tooth  or  teeth. 
If,  however,  on  the  removal  of  such  cause,  the  effect  does  not  sub- 
side, the  invoked  and  persistent  irritability  is  to  be  treated  on  such 
principles  as  commend  themselves.  Sweet  oil  and  paregoric  I  have 
found  act  very  happily.  To  each  teaspoonful  of  the  oil  add  from 
five  to  twenty  drops  of  the  opiate,  according  to  the  age  of  the  little 
patient.  Heating  applications  to  the  abdomen  are  most  useful ;  for 
example,  a  poultice  made  as  follows : 

Flour,  ^ss; 
Mustard,  5i ; 
Ginger,  5ij ; 
Black  pepper,  5ss. 
Mix  these  together  with  a  little  vinegar,  and  keep  to  the  skin  until 
it  is  well  reddened.     It  is  not  at  all  necessary  to  blister  the  surface. 

Another,  and  perhaps  a  more  comfortable  mode  of  treatment,  is  to 
give  small  doses  of  Dover's  powder,  or,  what  I  prefer,  the  liq.  potassse 
citratis,  in  conjunction  with  minute  doses  of  tartar  emetic. 

R. — Spts.  seth.  nit.  ^ss  ; 

Liq.  potassse  citrat.  ^ij ; 
Ant.  et  potass,  tart.  gr.  ^.     M. 
Give  in  ten-  to  fifteen-drop  doses  each  two  hours. 

If  the  inflammation  has  anything  of  a  sluggish  or  passive  char- 


106  ORAL  DISEASES  AND  SURGERY. 

actcr,  the  spts.  Mindereri  will  act  happily.     Half  teaspoonful  doses 
each  two  or  three  hours  to  be  given. 

Diarrhoea  from  dental  irritation,  not  inflammatory  in  character,  is 
to  be  treated  in  consideration  of  its  nervous  relation ;  and  just  here 
is  a  condition  in  which  the  bromide  of  potassium  acts  most  satis- 
factorily. It  may  be  given  in  five-grain  doses,  dissolved  in  water ; 
or,  if  the  practitioner  does  not  like  to  commence  in  the  infant  with 
such  a  dose,  he  may  try  if  less  will  answer  his  purpose,  and  in- 
crea.se  pro  re  nata.  Less  than  five  grains,  however,  I  do  not  think 
will  do  much  good,  unless,  indeed,  the  child  is  very  young.  Spts. 
Mindereri,  sweet  spirits  of  nitre,  and  the  camphorated  tincture  of 
opium  also  act  most  satisfactorily  in  these  cases.  They  may  be 
given  in  such  proportions  as  indicated.  An  ordinary  prescription 
would  be  about  the  following : 

B, — Spts.  Mindereri,  ^ij; 
Spts.  seth.  nit.  |ss ; 
Tinct.  opii  camph.  5ij-    M. 
Sig.  Twenty-five  drops  each  two  to  four  hours. 

The  following  combination  is  a  valuable  one,  when  other  sources 
of  irritation,  not  perhaps  thoroughly  appreciated,  exist  in  conjunc- 
tion with  the  dental  trouble : 

B. — Hydrarg.  chl.  mite,  gr.  ij ; 
Pulv.  opii, 

Pulv.  ipecac,  aa  gr.  i ; 
Mag.  carb.  gr.  xii.     M. 
Ft.  chart.  No.  xii. 
Sig.  Dissolve,  or  mix  with  any  convenient  vehicle,  one  of  these 
powders,  and  administer  after  each  operation,  if  profuse,  or  other- 
wise each  two,  three,  four,  or  five  hours,  according  to  judgment. 

4.  Spasvis. — To  appreciate  the  cause  and  condition  of  spasms  and 
convulsions  in  early  childhood,  whether  influenced  or  not  by  the 
excitement  of  dentition,  one  has  but  to  consider  the  restless  mobility 
of  the  cerebro-spinal  system  at  such  age.  If,  at  an  early  period  of 
life,  we  examine  the  gray  matter  of  the  spinal  cord,  we  are  struck 
with  its  development  when  compared  with  the  similar  substance  in 
the  cereliral  portion  of  the  encephalic  mass.  To  express  ourselves 
diflFcrently,  the  ganglion  of  excito-motor  or  reflex  action  we  find  to 
be  much  in  excess  in  its  development,  and  not  only  so,  but  sensitive 
and  susceptible,  as  its  ofiBces  are  concerned,  to  the  last  degree,— a 


ASSOCIATIVE  LESIONS   OF  FIRST  DENTITION.     107 

result  most  likely  of  the  necessity  for  the  motiou  of  growth  and 
development  existing  in  the  members  of  a  child ;  such  a  system 
may  be  compared  to  a  tensely  strung  instrument,  responding  to  the 
slightest  touch. 

The  difference  between  a  regular  and  irregular  motion  is  the  dif- 
ference between  mx  ability  or  disability  of  the  cerebellar  gray  matter 
to  perform  its  functions  of  co-ordination ;  the  difference  between  a 
co-ordinated  and  an  irregular  motion  is  the  difference  of  spasm,  and 
if  we  carry  it  to  the  disability  of  the  cerebral  mass  to  influence,  it 
is  the  difference  of  convulsion. 

Spasm,  then,  may  be  defined  to  be  irritation,  direct  or  indirect,  of 
the  spinal  cord  or  its  terminal  outshoots  or  nerves.  This  founda- 
tional principle  appreciated,  the  further  consideration  of  the  subject 
is  not  at  all  diflScult.  Yery  true  it  is,  that  there  may  be  causes  of 
disturbance  that  we  cannot  discover ;  but  the  results,  and  the  mean- 
ing of  them,  are  not  thereby  rendered  any  the  less  obscure  :  it  would 
be  only  the  cure  that  would  be  delayed  or  denied. 

We  are  prepared,  then,  to  recognize  in  what  way  dental  evolution 
is  a  cause  of  spasm :  it  is  precisely  as  it  is  a  cause  of  diarrhoea,  as  it 
is  a  cause  of  fever ;  but  the  reflected  irritation  in  the  latter  case 
expends  itself  on  the  muscular  system  rather  than  upon  the  mucous 
or  vascular.  The  cure  or  the  mode  of  cure  suggests  itself:  first, 
we  are  to  remove  the  condition  of  irritation  ;  second,  if  the  parts  do 
not  quickly  soothe  and  quiet  themselves,  we  are  to  help  them.  To 
meet  the  first  indication  we  simply  lance  the  gums.  I  do  not  think 
that  in  these  cases  we  are  to  be  influenced  too  entirely  by  local 
manifestations  of  congestion — cut  freely  down  upon  teeth  whose 
periods  of  eruption  suggest  them  as  being  the  source  of  offense. 
Take  a  pledget  of  cotton,  and,  saturating  it  with  solution  of  mor- 
phia, thrust  it,  by  means  of  some  delicate  instrument,  into  the  cut 
you  have  made.  This  is  quite  equal  to  the  more  fashionable  subcu- 
taneous injection,  and  tends  to  soothe  and  quiet  the  disturbed  nerve 
filaments.  If  yet  the  spasms  should  persist,  some  general  effect  on 
the  nervous  system  at  large  must  be  secured.  Tincture  of  valerian 
and  gentian  in  equal  parts,  given  in  ten-drop  doses,  repeated  pro  re 
nata,  will  sometimes  act  most  satisfactorily.  If  this  should  not 
answer,  the  bromide  of  potassium  may  be  employed.  The  bromide, 
cantharides,  and  camphor,  as  recommended  by  Dr.  Chambers  in 
epilepsy,  constitute  an  admirable  combination. 


108  ORAL  DISEASES  AND  SURGERV. 

B. — rotass.  brom.  gr.  iij ; 
Tinct.  cantharid.  gtt.  iij ; 
Mist,  camphorae,  gtt.  x.     M. 
Sig.  Give  this  in  a  little  water  three  or  four  times  a  day. 

If,  after  proper  trial  of  the  above — say  a  few  days— the  irritability 
fails  to  be  subdued,  the  inference  will  be  that  our  diagnosis  has 
been  a  mistake,  and  that  dentition  is  not  wholly,  at  least,  in  fault. 

At  this  point  we  see  the  necessity  of  glancing  at  other  causes 
of  irritation  which  may  exist.  Many  children  incline  to  nervous 
derangements  from  anaemia;  this  we  know  to  be  a  quite  common 
cause  of  such  derangements.  An  anemic  condition  might  not 
of  itself,  in  a  special  case,  induce  spasm,  but  assisted  by  conjunc- 
tion with  a  second  irritant,  the  two  together  could  excite  to  the 
condition ;  and  one  removed,  the  other  could  very  well  resist  a  cura- 
tive agent.  A  glance  here  shows  us  why  the  sedative  has  not 
effected  the  cure ;  let  us  add  iron  to  our  prescription,  and  a  very  few 
more  days  will  give  us  a  different  result.  Perhaps,  on  the  contrary, 
the  condition  of  a  child  is  just  the  reverse ;  instead  of  being  anemic 
it  is  plethoric.  Give  to  this  child  repeated  do.ses  of  some  suitable 
saline  mixture,  and  conjoin  with  the  potassium  quarter-grain  doses 
of  calomel ;  or,  if  you  do  not  wish  thus  to  medicate,  starve  it  for 
a  few  days,  give  it  nothing  but  the  breast,  and  this  only  in  the 
daytin)e;  or,  if  the  period  is  that  of  second  dentition,  deprive  it 
of  all  but  vegetable  food,  with  water  for  drink ;  a  cm"e  would  most 
likely  follow  such  treatment.  Lack  of  good,  fresh,  pure  air,  un- 
wholesome food,  deficient  or  improper  clothing,  sleeping  with  de- 
bilitated persons,  the  milk  of  the  nurse,  articles  of  food  not  easy  of 
digestion,  hepatic  derangements,  worms  in  the  alimentary  canal, 
influences  passed  from  mother  to  infant,  and  numberless  similar 
conditions,  are  exciting  and  predisposing  causes  of  spasm  and  con- 
vulsions ;  and  all  demand,  in  every  case,  their  share  of  consideration, 
if  we  are  to  be  successful  in  treatment. 

Spasm  resulting  from  the  congestion  of  nerve  centers,  however 
induced,  is  not  unfrequently  tonic  in  its  character ;  the  child  may 
lose  all  consciousness;  it  passes  into  the  state  that  we  call  con- 
vulsion. In  these  cases  results  must  be  obtained  immediately;  we 
must  relieve  the  overburdened  part.  How?  By  derivation.  Try 
first  a  hot  foot-bath ;  let  it  be  as  hot  as  the  skin  will  bear  it.  Inclose 
the  steam  of  the  water  so  that  it  shall  envelop  all  of  the  child  but 
its  head ;  compel  it,  if  possible,  to  take  teaspoonful  doses  of  the  spirits 


ASSOCIATIVE  LESIONS   OF  FIRST  DENTITION.     109 

Mindereri.  The  steam,  or  the  steam  and  mixture  in  conjunction, 
will  soon  compel  profuse  perspiration,  and  thus  secure  a  double  de- 
riv^ation.  Such  treatment  will,  most  likely,  relieve  the  congested 
part ;  at  least  it  has  generally  proved  most  reliable  in  my  hands.  If 
it  should  not  answer  the  intention,  then  a  vein  may  be  opened,  or 
leeches  may  be  applied.  The  opening  of  a  vein  in  such  cases  I 
have  never  had  occasion  to  resort  to,  but  it  is  good  practice,  and 
is  recommended  by  the  best  writers.  The  pediluvia  and  deriva- 
tion by  perspiration,  I  think,  however,  will  be  found  reliable. 
If,  after  consciousness  is  restored,  the  pulse  continues  rapid,  with 
fullness,  give  one-drop  doses  of  the  tinct.  verat.  vir.,  or  relax  the 
system  generally  by  doses  of  tinct.  lobelia  or  ipecacuanha.  Ten 
drops  of  either  of  these  medicines  will  very  well  answer  the  pur- 
pose. Keep  the  child  now  cool,  and  guard  against  every  source  of 
discomfort. 

Passive  congestions  are  sometimes  a  cause  of  infantile  spasms ; 
these  are  not  difficult  to  distinguish  from  the  acute  or  active  con- 
ditions, the  languor  and  sluggishness  markedly  contrasting  with 
the  turgidity  and  fullness.  Again,  it  is  distinguished  from  the 
active  condition  in  its  results,  these  being  not  immediate,  but 
mediate.  Passive  congestions  depend  on  some  obstruction  in  the 
circulatory  apparatus,  and  are,  perhaps,  more  frequently  associated 
with  the  chylopoetic  than  with  any  other  system.  Stagnations 
occur  as  a  result  of  some  interference  with  the  respiratory  office,  or 
they  may  be  the  result  of  the  action  of  some  directly  sedative  poison. 
Wherever,  and  however  they  exist,  they  are  to  be  removed,  if  pos- 
.sible,  by  meeting  and  combating  the  cause,  which,  of  course,  is  the 
only  philosophy  of  cure. 

"In  cases  of  pure  irritation,"  sa3"S  Dr.  Wood,  "besides  removing 
the 'Cause,  it  is  proper  to  diminish  the  nervous  susceptibility  and  to 
control  the  cerebral  irritation  by  diffusing  the  excitement  over  the 
whole  system.  To  meet  the  first  indication,  narcotics  may  be  em- 
ployed ;  and  none  is  more  efficacious  than  opium,  which,  to  di- 
minish its  stimulant  influence,  may  be  combined  in  some  instances 
with  ipecacuanha.  Hyoscyamus,  lactucarium,  or  conium  may  be 
substituted,  if  on  any  account  thought  preferable.  But  before  re- 
sorting to  these  remedies,  the  practitioner  must  be  very  sure  of  his 
grounds.  He  must  be  quite  convinced  that  it  is  nervous  irritation, 
and  not  active  congestion  of  the  brain,  that  he  has  to  encounter. 
The  second  indication,  above  alluded  to,  is  to  be  fulfilled  by  antispas- 
modics, administered  by  the  mouth,  the  rectum,  or  the  skin,  and  by 


110  ORAL  DISEASES  AND  SURGERY. 

the  use  of  tonics,  of  which  the  metallics  are  deemed  most  efficient. 
Of  these  the  oxide  of  zinc  has  perhaps  enjoyed  most  reputation, 
thoug'h  the  chalybeates  shouhl  be  preferred  in  anemic  cases.  Should 
the  digestion  be  impaired,  and  the  system  at  large  feeble,  the  simple 
bitters  or  quinia  might  be  preferable  to  the  metallic  tonics.  These 
remedies  may  often  be  combined  in  the  same  prescription.  Thus, 
opium  or  hyoscyamus,  assafetida,  and  either  oxide  of  zinc,  carbonate 
of  iron,  sulphate  of  quinia,  or  extract  of  gentian  or  quassia,  may 
very  properly  go  together.  The  cold  or  shower-bath,  cautiously 
used,  may  also  serve  to  strengthen  the  nervous  system.  Fresh  air 
and  nutritious  diet  of  easy  digestion  are  important.  Any  derange- 
ment in  the  hepatic  secretions  should  be  carefully  observed,  and 
treated  with  minute  doses  of  calomel,  blue  pill,  or  mercury  with 
chalk.  When  the  disease  depends  on  intestinal  spasm,  great  ad- 
vantage will  often  accrue  from  the  use  of  laudanum,  with  assafetida 
or  spirits  of  ammonia  by  the  mouth,  the  injection  of  musk  into  the 
rectum,  the  application  of  a  mustard  cataplasm,  or  blister  over  the 
abdomen ;  and  if,  as  often  happens,  the  bowels  are  distended  with 
flatus,  from  the  Introduction  of  a  catheter  into  the  colon,  and  draw- 
ing off  the  air  by  means  of  a  syringe.  Should  the  disappearance  of 
an  eruption  have  preceded  the  convulsions,  efforts  should  be  made 
to  restore  it  by  friction  with  croton  oil  or  other  active  irritant.  In 
urgent  cases  a  blister  might  be  produced,  by  means  of  a  strong 
solution  of  ammonia,  on  the  surface  previously  affected. 

"  In  frequently  recurring  convulsions,  resisting  other  measures, 
and  threatening  life,  the  practitioner  would  be  justified  in  resorting 
to  the  inhalation  of  chloroform,  which  will  often  quickly  quiet  the 
spasms;  and  if  reapplied  with  each  return,  may  obviate  the  danger 
until  the  tendency  is  past.  It  has  the  advantage,  moreover,  over 
other  narcotics,  of  not  congesting  the  cerebral  centers,  though^the 
danger  of  fatal  prostration  from  its  use  must  not  be  forgotten. 

"  Even  when  asphyxia  or  apparent  death  may  have  resulted  from 
the  convulsions,  hope  should  not  be  abandoned ;  but  efforts  should 
be  made  by  artificial  respiration  to  restore  the  functions  of  the  lungs, 
and  consequently  that  of  the  heart." 

Finally,  on  this  subject,  I  may  direct  attention  to  the  connection 
between  the  troubles  we  are  considering  and  the  predispositions  of 
an  hereditary  nature,  so  often  found  in  association.  When  these 
deteriorative  conditions  exist,  it  is  a  necessity  for  success  in  treat- 
ment that  we  consider  and  combat  them. 

5.  EruiMons.— That  the  skin  of  childhood  should  be  the  subject 


ASSOCIATIVE  LESIONS   OF  FIRST  DENTITION.     HI 

of  irritative  changes  is  certainly  only  what  is  to  be  expected,  and 
that  variations  in  condition  do  most  frequently  occur  is  as  true  as 
that  they  are  thus  expected. 

Certain  general  considerations  of  the  subject  give  us,  I  think,  the 
kej^-note.  Thus,  in  the  beginning,  a  momentary  thought  directed 
to  the  great  change  v^^hich  must  result  in  the  passage  from  intra-  to 
extra-uterine  life,  would  naturally  lead  to  the  anticipation  of  a 
cutaneous  hyperemic  condition  at  once  to  be  developed.  In  intra- 
uterine life  we  not  only  have  the  delicate  and  susceptible  skin  lubri- 
cated with  the  soft,  bland  smegma,  but  pressure  on  any  and  every 
part  is  jealously  guarded  against  by  the  surrounding  amniotic  fluid. 
A  single  minute,  frequently,  and  the  most  irritative  changes  occur : 
the  waters  pass  away,  the  uterus  crowds  and  passes  upon  every 
part  of  the  child,  while  the  outside  world,  still  less  considerate,  re- 
ceives it  on  its  birth,  its  atmosphere  stimulating  and  irritating,  its 
rough  points  jagging  and  abrading,  while  unnecessary,  and  too  fre- 
quently ill-advised,  appliances  and  applications  add  to  the  common 
discomfort. 

Cutaneous  hyperismia — erythema,  as  it  is  generally  called — is  a 
child's  primary  skin  trouble.  Such  an  erythema  is  certainly  nothing 
more  nor  less  than  the  variegated  blush  of  an  overstimulated  circula- 
tion. Perhaps  if  the  smegma  were  left  undisturbed  for  a  few  hours, 
just  as  nature  smeared  it  over  the  body,  or  until  the  skin  had  be- 
come somewhat  accustomed  to  its  new  atmosphere,  such  hypersemia 
would  be  avoided ;  but  as  such  excitability  seems  to  do  no  im- 
mediate harm  to  the  child,  neither  nurse  nor  mother,  I  imagine, 
would  be  found  satisfied  with  such  an  arrangement.  But  does  this 
hypersemia  do  no  harm  ?  Does  it  not  provoke  an  excitability  in  the 
skin  which  would  be  better  absent  ?  Certainly  children  are  most 
susceptible  to  cutaneous  impressions,  as  witnessed  not  only  in  colds 
so  easily  taken,  but  by  the  variety  of  local  manifestations,  to  the 
relief  of  which  the  practitioner  is  so  frequently  called.  Dental  irri- 
tations pertain  to  these  troubles  only  as  they  act  as  excitants  to 
the  pre-existing  predisposition,  or  as  they  keep  up  an  excitability 
which  overmasters  the  corrective  force  natural  to  the  vis  vitse. 

Hyperemia  running  into  an  excess  is  inflammation.  Inflamma- 
tion of  the  skin  finds  a  primary  expression  in  the  term  dermatitis. 
A  dermatitis  has  secondary  signification,  as  it  presents  peculiarities 
which  lead  us  to  look  for  reasons  for  such  expressions  Thus,  one 
inflammation  in  the  skin  is  a  simple  sthenic  increased  vascularity, 
having  the  phenomena  of  redness,  heat,  pain,  and  swelling.     A 


112  ORAL  DISEASES  AND  SURGERY. 

second  is  not  regular  and  honest  in  its  expressions,  but  throws  out 
claw-like  expansions,  and  looks  dusky  and  threatening,  throwing  to 
the  surface,  here  and  there,  blebs  of  serum.  We  distinguish  this 
second  from  the  first  by  the  subterm  erysipelas,  or  erysipelatous  in- 
flammation. Then  we  have  an  inflammation  which  presents  the 
peculiarity  of  studding  the  face  of  the  skin  with  pustules,  and  this 
derangement  we  distinguish  by  the  term  pustulae  or  pustular  inflam- 
mation. Another  form  which  covers  the  inflamed  surface  with 
vesicles;  another  which  throws  out  groups  of  nodules — papular; 
another  which  circumscribes  its  redness  to  patches  —  rashes;  an- 
other which  presents  raised  or  elevated  patches — urticaria,  etc.  All 
having  alike  the  primary  signification  of  a  perverted  circulation,  but 
diS"cring  in  presenting  each  distinctive  phenomena,  which  mark  dif- 
ferences in  local  or  constitutional  circumstances. 

That  dental  irritation  develops  or  creates  the  distinctive  features 
in  a  skin  disease  is  sheer  nonsense.  All  that  such  irritation  can 
have  to  do  with  the  matter  is  that  it  exhausts  the  system,  just  as 
any  pain  exhausts  and  tires  us,  and  reduces,  as  remarked,  the 
ability  of  the  vital  force  to  guard  or  protect  itself  against  an  enemy 
or  enemies  in  waiting  at  the  threshold.  It  does  not  make  the 
enemy,  it  only  lets  him  in  b}^  weakening  the  bars. 

That  a  skin  disease  is  thus  introduced,  and  continued  in  an  ability 
to  resist  applied  medication,  is  true  beyond  the  shadow  of  a  doubt; 
and  it  is  for  such  a  reason  that  the  consideration  of  dental  irritation, 
in  connection  with  infantile  skin  diseases,  is  most  important ;  and 
yet  this  study,  as  the  evolution  of  the  teeth  are  concerned,  difl"ers  in 
no  wise  from  its  study  in  relation  to  stomatitis,  diarrhoea,  or  spasm,  as 
certainly  any  intelligent  mind  must  at  once  appreciate.  It  does  differ, 
however,  as  far  as  a  collateral  treatment  is  concerned,  and  such  treat- 
ment implies  the  study  of  skin  diseases,  as  in  works  on  dermatology 
the  subject  is  presented.  It  comes  within  our  province  here,  however, 
simply  to  state  some  generalizations  in  such  a  direction, — an  idea,  if 
the  reader  pleases,  as  to  the  mode  which  such  an  investigation  might 
be  entered  upon  to  compel  it  more  readily  to  yield  to  us  its  secrets. 

A  thousand  complex  scientific  terms  would  scarcely  exhaust  the 
vocabulary  of  the  dermatologist  of  the  signification  he  has  for  the 
varieties  and  modifications  of  pathological  skin  phases.  These 
thousands  of  conditions,  however,  are  found  to  revolve  around  eight 
centers,  as  radii  from  a  star.  The  center  of  each  is  the  nucleus  or 
pith  of  the  divisions,  and  the  subdivisions  are  but  radii  of  the  com- 
mon substance. 


ASSOCIATIVE  LESIOXS   OF  FIRST  DENTITION.     113 

All  skin  diseases  belong  to  one  of  eight  orders : 
1st.  Pimples. 
2d.  Scales. 
3d.  Rashes. 
4th.  Bullffi. 
5th.  Pustules. 
6th.  Vesicles. 
"Zth.  Tubercles. 
8th.  Spots. 

1.  Pimples — Papulse. — Small  and  pointed  elevations  of  the  cuticle, 
with  an  inflamed  base — very  seldom  containing  fluid,  seldom  sup- 
purating, and  commonly  resolving  as  scurf. 

Three  primary  divisions  of  papules  are  made:  strophulus,  lichen, 
and  prurigo. 

Secondary  divisioiis. — Strophulus  intertunctus. 

S.  albidus,  S.  confertus,  S.  volaticus,  S.  candidus. 

Lichen  simplex,  L.  pilaris,  L.  circumscriptus. 

L.  agrius,  L.  lividus,  L.  tropicus. 

Prurigo  mitis,  P.  formicans,  P.  senilis, 

P.  pudendi  muliebris. 

2.  Scales — Scaly  Diseases — Squamae. — Scales  or  lamina  form 
upon  the  skin.  Scales  are  of  various  forms.  In  some  cases,  as  in 
pityriasis,  resembling  a  scurf;  in  other  cases,  as  in  ichthyosis,  being 
broad  and  flattened,  and  bearing  likeness  to  fish  scales.  To  mark 
the  various  prominent  differences,  four  varieties  are  enumerated: 
Psoriasis,  Lepra,  Pityriasis,  Ichthyosis. 

Subdivisions. — Lepra  vulgaris,  L.  alphoides,  L.  nigricans. 
Psoriasis  guttata,  P.  diffusa,  P.  gyrata. 
P.  inveterata. 

Pityriasis  capitis,  P.  rubra,  P.  versicolor,  P.  nigra. 
Ichthyosis  simplex,  I.  cornea. 
3  Ba.'ihes — Exanthemata. — Irregular,  variously  figured  patches, 
appearing  on  various  parts  of  the  body,  leaving  interstices  of  a 
natural  color,  and  terminating  in  exfoliations  of  the  cuticle.  The 
designation  is  generally  limited  to  efflorescences,  originating  in  fevers, 
as  for  example  measles  and  scarlet  fever. 

Bateman,  however,  includes,  and  perhaps  more  philosophically, 
Erythema,  Urticaria,  and  Purpura  in  the  division. 

The  first  division  is,  then,  according  to  Bateman,  Rubeola,  Scarla- 
tina, Urticaria,  Purpura,  Erythema. 


114  ORAL   DISEASES  AXD  SURGERY. 

Subdivisions.— llnhco]a  vulgaris,  Scarlatina  simplex. 

S.  anginosa,  S.  maligna,  Urticaria  febrilis,  TJ.  evanida. 

TJ.  persistans,  U.  conferta,  U.  subcutanea. 

U.  tuberosa,  Purpura  simplex,  P.  hsemorrhagica. 

P.  urticans,  P.  senilis,  P.  contagiosa,  Erythema  Iseve. 

E.  papulatum,  E.  tuberculatum,  E.  nodosum, 

4.  JiuUee. A  condition  in  which  effusion  occurs  on  the  true  skin, 

separating  the  cuticle  in  the  form  of  blebs  or  blisters.  An  effusion 
developed  by  a  blister  comes  justly  in  its  consideration  under  this 
head,  for  it  is  surely  not  less  a  bleb  that  have  produced  it — the  dif- 
ference between  such  a  bleb  and  one  produced  by  an  erysipelatous 
inflammation  is  that  one  has  strictly  a  local  signification,  while  the 
second  is  a  systemic  condition.  Blebs  or  bullae  have  three  primary 
classifications:  Erysipelas,  Pemphigus,  Pompbolyx. 

The  subdivisions  are  into  J^rj^sipelas  phlegmonodes,  E.  oedema- 
todes,  E.  gangrenosum,  E.  crraticum,  Pompholyx  benignus,  P.  dinu- 
turus,  P.  solitarius. 

5.  Pustules — Pustulse. — An  inflammation  of  the  skin,  resulting  in 
the  formation  of  purulent  matter,  which  accommodates  itself  by 
throwing  up  little  circumscribed  tumors.  Whether  one  or  many  of 
these  pustules  rise  on  a  common  inflamed  base  depends  on  the 
fundamental  or  exciting  cause ;  and  because  the  conditions  which 
produce  pustular  inflammation  vary,  so  have  we  various  names  by 
which  to  distinguish  and  appreciate  these  causes.  Five  primary 
pustular  inflammations  exist:  Impetigo,  Porrigo,  Ecthyma,  Yariola, 
Scabies. 

The  subdivisions  are  numerous,  depending  on  peculiarity  of  fea- 
tures. Impetigo  figurata,  I.  sparsa,  I.  erysipelatodes,  I.  scabida,  I. 
rodens,  Porrigo  larvalis,  P.  furfurans,  P.  lupinosa,  P.  scutulata,  P. 
decalvans,  P.  favosa.  Ecthyma  vulgare,  E.  luridum,  E.  cachecticum, 
Yariola,  Scabies  papuliformes,  S.  lymphatica,  S.  purulenta,  S. 
cachectica. 

6.  Vesiculse — Vesicles. — Yesicles  differ  from  pustules  in  con- 
taining lymph— they  look  like  little  water  pimples,  although  it  is 
very  frequently  the  case  that  the  contained  lymph  is  quite  opaque: 
the  end  of  a  vesicle  is  by  scurf  or  scab.  There  are  seven  primary 
varieties:  Yaricella,  Yaccinia,  Herpes,  Rupia,  Miliaria,  Eczema, 
Aphtha. 

The  subdivisions  are  Yaricella  lenticulus,  Y.  conoidaj,  Y.  globate. 
Herpes  phlyctaenodes,  H.  zoster,  H.  circinatus,  H.  labialis,  H.  pra- 
putialis,    H.  iris,  Rupia   simplex,    R.    prominens,    R.  escharotica. 


ASSOCIATIVE  LESIONS   OF  FIRST  DENTITION.     115 

Eczema  solare,  E.  impetiginodes,  E.  rubrum,  Aphtha  lactantiuni,  A. 
actultorum,  A.  anginosa. 

7.  Tubercula — Tubercles. — These  are  small,  hard,  circumscribed 
tumors — they  may  be  fixed  in  a  state  of  integrity,  or  they  may  be 
degenerative.  There  are  eight  kinds  of  these  tumors — or,  to  express 
it  differently,  there  are  eight  distinctive  differences:  Phyma,  Ver- 
ruca, Molluscum,  Vitiligo,  Acne,  Sycosis,  Lupus,  Elephantiasis, 
Framboesia. 

Among  these,  subdivisions  seem  only  necessary  with  acne  and 
sycosis.  Thus,  there  are  three  peculiarities  in  acne,  which  are 
marked  by  the  terms  Simplex,  Indurata,  Rosacea.  In  sycosis, 
Sycosis  menti,  and  S.  capillitii,  designating  the  location  of  the 
tubercules. 

8.  Macula — Spot — Mother-Mark — Freckles  or  Ejjhelis — Neevus. 

These  eight  classifications,  after  Bateman,  with  his  subdivisions, 
make  out  of  skin  diseases  all  that  they  deserve.  It  is  for  the  student 
to  comprehend  the  primary  divisions,  as  their  pathological  differ- 
ences are  concerned  ;  the  radii,  or  subdivisions,  will  be  found  to  take 
care  of  themselves.  Without  an  understanding  of  the  general  sub- 
ject one  could  scarcely  expect  to  appreciate  any  accidental  or  positive 
dental  relations.  The  subdivisions  will  be  remarked,  on  examina- 
tion, to  be  simply  as  family  surnames  distinguishing  one  child  from 
another ;  it  is  true,  of  course,  that  there  are  peculiarities  of  char- 
acter, just  as  each  child  is  peculiar,  and,  by  such  peculiarities,  are 
these  modifications  on  the  primary  condition  named.  Now,  it  is  not 
by  any  means  common  to  associate  all  these  conditions  with  dental 
irritations ;  yet  it  is  certainly  true  that  any  one  of  them  may  have 
such  association :  therefore,  if  the  student  would  understand  one  he 
must  understand  all. 


CHAPTER    VI. 

ANOMALIES   OF   SECOND   DENTITION   AND  THEIR   SURGICAL  RELATIONS. 

Anomalies  in  second  dentition  may  be  classed  under  seven  heads: 

1st.  Tci'th  common  to  the  age,  but  erupting  external  or  internal 
to  the  arch. 

2d.  Teeth  denied  space  in  the  arch,  because  of  natural  or  surgical 
interference  with  the  process  of  maxillary  enlargement. 

3d.  Germs,  developing  in  positions  where  their  product  must 
remain  encysted. 

4th.  The  production  of  supernumerary  teeth. 

5th.  Third  dentitions. 

6th.  Teeth,  the  periodonteum  of  whose  fangs  is  in  association 
with  the  periosteum  of  the  sinus  maxillare. 

7th.  Germs,  with  heterogeneous  development. 

These  seven  conditions,  then,  because  they  differ  from  a  just  or 
normal  dental  evolution,  we  call  anomalies. 

Anomaly  First. — A  tooth  external  or  internal  to  the  alveolar 
arch  not  unfrequently  gives  origin  to  an  ulcer  or  locates  epithelioma. 
Yet  close  as  is  this  primary  to  the  secondary  lesion,  and  evident  as 
such  relationship  would  seem  to  be,  I  have  known  ulcers  of  the 
tongue,  lips,  and  cheeks  treated  for  months — of  course,  without  suc- 
cess— where  it  has  never  seemed  to  strike  the  practitioner  that  the 
tooth  could  have  any  association  with  the  disease ;  indeed,  in  one 
case,  where  the  patient  was  remotely  connected  to  myself,  a  horrible 
death  was  the  result  of  a  cancer  located  in  the  cheek  from  this  very 
anomaly. 

Note. — Even  where  there  is  excess  of  room,  the  permanent  teeth 
not  unfrequently  erupt  irregularly  ;  indeed,  this  applies  so  directly 
to  the  inferior  incisors,  that  it  may  almost  be  said  to  be  the  rule 
rather  than  the  exception.  Unless,  however,  specially  indicated,  it 
is  the  best  practice  to  leave  them  to  nature  ;  they  will  almost  always 
be  found  to  come  right  of  themselves.  I  would  be  understood  as 
classing  them  with  the  anomalies  only  as  the  derangement  is  marked 
and  permanent. 
(116) 


ANOMALIES   OF  SECOND   DENTITION.  117 

Anomaly  Second. — Teeth  denied  space  in  the  arch.  This  anomaly 
has  perhaps  the  largest  associative  pathological  connection. 

I  remarked  that  this  lesion,  if  we  may  term  it  such,  is  more  fre- 
quently the  fault  of  the  surgeon  than  of  nature.  If,  for  one  moment, 
we  refer  to  certain  physiological  relations  existing  between  the  first 
and  second  dentures,  we  may  find  that  it  is  within  our  power  to 
prevent  the  many  ills  that  follow  so  frequently  in  this  train,  and 
simply  by  doing  little,  or,  more  commonly,  nothing. 

The  deciduous  dental  arch  is  filled,  as  we  are  all  aware,  com- 
pletely by  its  ten  teeth.  The  second  or  permanent  set  is  to  comprise 
in  number  sixteen,  and  each  tooth  certainly  quite  as  large  again  as 
its  predecessor.  This  increase  in  number  and  size  of  the  teeth,  it  is 
evident,  must  be  provided  for  in  an  enlargement  of  the  alveolar 
arch.  This  provision  is  always  attempted  by  nature  in  the  process 
described  by  the  physiologist  as  the  elongatory. 

I  will  illustrate  this  process  of  maxillary  enlargement  by  con- 
sidering the  ten  milk  teeth  as  so  many  wedges  placed  in  a  springy 
arch.  This  arch  it  is  designed  to  lengthen  by  additions  to  either 
end.  If,  now,  these  wedges  should  be  removed  before  others  were 
ready  to  take  their  place,  it  is  evident  that  the  elongation,  being- 
made  at  the  ends,  would,  to  a  greater  or  less  extent,  be  counter- 
balanced by  the  springing  together  of  the  parts  at  the  sites  of  the 
removed  wedges.  The  process  of  maxillary  or  rather  alveolar  ab- 
sorption, is  truly  represented  by  this  retraction  of  an  arch  *  In  pro- 
portion to  the  number  of  deciduous  teeth  removed  prematurely,  will 
be  the  curtailment  in  size  of  that  arch,  at  least  of  its  alveolar  face. 

Let  us,  then,  look  at  the  results  of  such  abridgment — approximal 
caries  of  the  teeth,  periosteal  troubles,  trismus,  odontocele,  necrosis, 
the  violent  inflammations  attendant  on  the  development  of  the  dentes 
sapientiae,  etc. 

Note. — If  there  is  a  pathological  Pandora's  box,  it  is  certainly  the 
lesion  of  an  overcrowded  maxillary  arch. 

Such  condition  is  made  evident  to  the  practitioner  the  moment  he 
looks  into  the  mouth  of  his  patient:  the  teeth  are  jammed  into 
the  most  uncomfortable-looking  positions ;  the  deformity,  however, 
mostly  existing  in  the  front  of  the  mouth, — either  the  central  incisors 
override,  or  the  laterals  are  thrown  back,  or  otherwise  the  cuspidati 

*Prof.  Gross,  and  Mr.  Tomes  also,  in  his  last  book,  denies  this  position; 
why,  I  know  not.  With  the  greatest  possible  respect  for  the  opinion  of  these 
gentlemen,  it  is  my  experience  that  they  are  wrong. 


118  ORAL   DISEASES  AND    SURGERY. 

take  the  tu^=k  position,  standing  out  prominently  from  the  arch,  the 
bicuspids  occupying  too  anterior  a  location,  approximating,  indeed, 
not  unfrcquontly  with  the  lateral  incisors. 

2Vcalmcn(.— To  abort  the  ill  consequences  of  such  a  contracted 
arch,  extract  at  as  early  a  period  as  possible  the  bicuspids  of  either 
side.'  This  very  simple  operation  will  frequently  not  only  secure 
against  secondary  lesions,  but  will  occasionally  correct  the  most  an- 
noying deformities.  But  let  it  be  remembered  by  the  practitioner 
who  prefers  prophylactic  to  operative  surgery,  that  on  his  treatment 
of  the  deciduous  mouth  depends,  in  a  measure,  the  health  and  com- 
fort of  the  adult. 

If  I  am  asked  what  is  to  be  done  with  the  deciduous  aching  tooth, 
I  may  answer  that  the  tooth  should  have  been  filled  on  the  first  ap- 
pearance of  decay;  the  dentist  has  in  his  armamentum  plastic  ma- 
terials which  he  can  employ  in  such  cases,  and  which  will  be  found 
to  answer  admirably  the  purpose  of  their  intention. 

Equal  parts  of  chloroform  and  tinct.  aconite  applied  to  the  nerve 
on  a  delicate  pellet  of  cotton,  will  sometimes  instantaneously  cure 
this  form  of  toothache.  Arsenical  applications  are  not  unfrcquently 
employed,  but  unless  the  practitioner  is  very  conversant  with  the 
physiological  change  that  occurs  in  the  fangs  of  these  teeth  he  had 
better  not  use  it ;  if,  however,  he  feels  prepared  to  employ  escha- 
rotics,  he  can  prepare  no  formula  better  than  the  following : 

R. — Acidum  arsenicum, 

Morphias  sulph.  aa  gr.  x; 

Creasote,  q.  s.  to  make  a  thick  paste. 

This  is  the  paste  so  universally  employed  by  the  bettor  class  of 
dentists  for  destroying  the  pulps  of  adult  teeth.  To  apply  it,  take  a 
piece  not  larger  than  a  pin's  head,  and  dropping  it  lightly  into  the 
cavity,  cover  loosely  with  cotton  ;  the  cavity  is  washed  out  with 
warm  water  after  ten  or  twenty  hours.  I  would  not  leave  it  in  a 
deciduous  tooth  over  ten  hours ;  and  if  absorption  of  the  fang  had 
advanced  to  any  extent,  even  one  might  be  too  long.  Employ  it 
fearlessly  in  the  adult  mouth,  only  remembering  you  deal  with 
arsenic,  but  with  the  child  be  careful.  Equal  parts  of  tinct.  of 
iodine  and  Monsel's  solution  of  the  perchloride  of  iron  is  also  an 
admirable  application.  I  have  stopped  a  raging  odontalgia  instan- 
taneously with  this  combination.  Give  the  mother  a  prescription 
for  this  last,  or  some  sedative  formula,  but  do  not  pull  out  the  teeth. 
The  central  incisors  of  the  deciduous  set  should  last  until  the 


ANOMALIES   OF  SECOND    DENTITION.  ng 

seventh  year;  the  laterals  until  the  eighth;  the  first  deciduous  molar 
until  the  ninth  year ;  the  second  until  the  tenth ;  the  deciduous 
cuspid  until  the  eleventh ;  and  let  it  be  remembered  that  the  most 
posterior  molar  teeth  that  are  in  the  mouth  at  the  sixth  year  are 
the  first  permanent  molars,  and  that  these  teeth  get  their  place  in 
the  jaw,  without  displacing  any  of  the  deciduous. 

For  an  account  of  some  of  these  secondary  lesions,  together  with 
treatment,  see  a  future  page. 

Anomaly  Third. — This  anomaly  is  remarked  by  examination  of 
the  classes  of  teeth  erupted.  Teeth  all  erupt  in  pairs,  so  that  one  is 
not  likely  to  be  deceived.  The  anomaly  is  not  unfrequently  the  re- 
sult of  interference  with  the  development  of  the  germ  of  the  perma- 
nent through  non-absorption  of  the  root  or  roots  of  the  deciduous 
teeth. 

Example. — A  deciduous  central  incisor  erupts — as  the  rule — about 
the  seventh  month,  and  is  succeeded  by  the  permanent  at  the  seventh 
year.  Now  the  physiological  relation  existing  between  the  two 
teeth  is  as  follows :  at  the  time  when  the  deciduous  has  attained 
its  fullest  development  the  germ  of  the  permanent  is  at  its  apex. 
Retrograde  metamorphosis  now  commences  in  the  fang  of  the  de- 
ciduous, while,  in  an  inverse  ratio,  the  development  of  the  perma- 
nent advances.  Now,  it  sometimes  happens  that  no  process  is  set 
up  for  the  taking  away  of  these  deciduous  fangs,  and,  as  a  conse- 
quence, the  permanent  are  compelled  to  make  alveoli  for  themselves  ; 
this  they  generally  do  by  emerging  posterior  to  the  deciduous ;  but, 
as  can  readily  be  imagined,  odoytocele  or  encystment  is  not  unfre- 
quently a  result. 

Note. — Sometimes,  long  after  the  period  at  which  the  second 
dentition  is  usually  completed,  the  incisors,  as  would  seem  to  be 
natural,  may  be  remarked,  each  occupying  its  respective  alveolus. 
Yet  here  we  may  have  odontocele.  One  of  the  incisors  that  we  see 
is  a  milk  tooth.  This  anomaly  could,  however,  deceive  only  the 
very  superficial  observer,  the  difference  in  the  classes  of  teeth  being 
sufficiently  marked. 

Because  of  this  non-absorption  of  deciduous  fangs,  arrest  in  the 
development  of  the  permanent  sometimes  occurs.  It  is  really  quite 
a  nice  point  in  practice  to  give  advice  in  such  cases ;  if  you  direct 
the  extraction,  and  no  tooth  comes  to  replace  the  one  lost,  you  will 
be  sure  to  get  a  good  deal  more  censure  than  you  could  possibly 
deem  yourself  deserving. 

There  are  a  number  of  conditions  to  take  into  the  consideration 


120  ORAL  DISEASES  AND   SURGERY. 

of  such  a  case— the  most  pronunent  one  of  which  is,  the  existence 
or  non-existence  of  the  anomaly  in  a  hereditary  point  of  view.  I 
am  acquainted  with  a  family  where  continued  integrity  on  the  part 
of  certain  front  teeth,  conjoined  with  the  non-appearance  of  the  per- 
manent, has  been  a  striking  peculiarity  as  far  back  as  the  ancestors 
can  be  remembered.  Ability  to  advise,  in  such  cases,  can  only  be 
gained  by  a  careful  study  of  the  laws  of  dentition. 

Surgical  Relations.— In  an  examination  of  any  obscure  tumor  of 
the  maxillary  bones,  examine  the  dental  arch ;  if  a  deciduous  tooth 
occupy  the  place  of  a  permanent,  the  existence  of  odontocele  may  be 
rea-onably  inferred. 

Anomaly  Fourth. — Supernumerary  Teeth. — These  teeth  differ 
from  all  others  in  being  doul)ly  conoidal ;  this  is  the  rule.  It  is,  how- 
ever, to  be  remembered  that  we  meet  with  exceptions.  Harris  men- 
tions having  seen  them  so  resembling  the  natural  teeth  as  "to  make 
it  impossible  to  distinguish  which  should  be  called  the  super- 
numerary;" as  for  myself  I  have  never  met  with  such  decided 
exceptions. 

An  encysted  condition  of  these  teeth  obscures  very  much  the 
recognition  of  their  existence.  In  diagnosing  diseases  of  the  mouth, 
we  must  bear  in  mind  that  we  have  such  odontoceles.  The  study 
of  their  evolution  is  very  interesting ;  but,  of  course,  concerns  the 
physiological  rather  than  the  surgical  author.  We  may  remark, 
however,  that  they  are  not  necessarily  a  dermatic  production,  and 
the  appearance  of  them  in  the  mouth  is  as  unaccountable  as  their 
association  with  ovarian  and  other  remote  tumors. 

Surgical  Relations. — With  the  exception  of  their  relation  to 
tumors,  we  have  only  to  deal  with  them  as  they  so  strangely 
present  themselves  in  the  mouth.  Let  me  give  an  example  of  such 
practice.  A  patient  presents  himself  and  tells  you  that  there  is  a 
piece  of  bone  working  out  through  his  mouth  ;  and,  truly,  an  exam- 
ination will  seem  to  verify  his  assertion.  But  there  is  one  point 
which,  if  observed,  will  never  mislead.  Necrosis  is  always  pre- 
ceded by,  and  is  associated  with,  inflammation.  The  eruption  of  a 
supernumerary  tooth  is  very  gradual,  and,  so  far  as  my  experience 
goes,  is  never  associated  with  inflammation.  To  extract  such  teeth, 
wait  until  they  have  emerged  to  the  base  of  the  cone ;  or,  if  such 
waiting  does  not  seem  desirable,  carefully  force  sharp-pointed  forceps 
through  the  bone  until  you  may  be  able  to  grasp  this  cone,  then 
with  a  rotary  motion  you  may  easily  pull  them  aw^ay.  Their  alveoli 
need  no  attention. 


ANOMALIES   OF  SECOND   DENTITION.  121 

Anomaly  Fifth. —  Third  Dentitions. — I  would  not  be  understood 
as  referring  here  to  that  extra  development  sometimes  occurring  in 
young  adult  life,  and  yet  the  mention  of  the  existence  of  such  an 
anomaly  is,  perhaps,  desirable.  Thus  Columbus  reports  that  one  of 
his  children  had  three  sets  of  teeth.  Valerius  Maximus  and  Pliny 
relate  similar  facts.  A  son  of  Mithridates  is  said  to  have  had  two, 
and  Hercules  three.  I  myself  have  seldom  seen  this  anomaly,  and 
incline  to  think  that  its  existence,  in  these  modern  times,  is  not  co- 
extensive with  the  ancient  period  I  have  certainly  had  quite  five 
hundred  persons  tell  me  that  such  and  such  tooth  or  teeth  were  the 
third  of  the  class,  but  examination,  in  almost  every  individual  case, 
has  satisfied  me  they  were  mistaken ;  this  anomaly  has,  however, 
surgically,  little  or  no  signification. 

Third  dentitions,  as  here  referred  to,  are  those  which  are  asso- 
ciated with  advanced  age.  The  student  will  recognize  their  phys- 
iology when  I  classify  them  with  second  sight,  etc.  The  lesions 
of  this  anomaly  are  what  might  be  termed  associative — that  is, 
we  are  occasionally  so  deceived  by  them  as  to  be  led  falsely  to  in- 
terpret engorgements,  congestions,  etc. 

A  single  case  will  illustrate  the  anomaly:  an  individual,  aged 
sixty-five,  applied  to  Dr.  Harris,  suffering  with  pain  in  the  gums 
and  jaws.  No  local  lesion  was  at  all  discoverable.  A  tentative 
treatment  was  resorted  to.  The  apparent  disease  went  on,  however, 
entirely  uninfluenced  by  the  experimental  medication,  until,  at  last, 
it  attained  an  intensity  positively  excruciating.  In  twenty-one  days 
the  mystery  was  explained  by  the  eruption  of  a  third  set  of  teeth. 

Anomaly  Sixth. — Association  of  the  odonto-periosteum  with  the 
membrane  of  the  antrum  of  Highmore. 

It  will  be  remembered  that  the  most  easy  entrance  to  the  max- 
illary sinus  is  through  the  palatine  fang  either  of  the  second  or  first 
molar  tooth.  It  is,  indeed,  as  I  well  know  from  experience,  a  very 
common  thing  to  find  the  roots  of  these  teeth  perforating  the  cavity. 
Remembering  this  association  of  parts,  it  will  be  seen  that  many 
conditions,  which  may  have  been  deemed  obscure,  are  thus  made 
very  plain.  Dr.  Harris,  who  was  a  close  observer  in  diseases  of 
the  mouth,  went  so  far  as  to  say  that  two  cases,  mentioned  by  Bell 
and  Bordenave,  were  the  only  authenticated  exceptions  where  ab- 
scess had  formed  in  this  cavity  at  any  other  point  than  that  at  which 
it  had  been  penetrated  by  the  root  of  a  tooth. 

A  case  mentioned  in  Braithwaite,  from  the  practice  of  a  Mr.  Louis 
Oxley,  of  London,  illustrates  most  happily  the  relations  of  this 


122  ORAL  DISEASES  AND  SURGERY. 

lesion :  A  young  woman,  of  rather  strumous  habits,  complained  of 
a  (hill,  aching  pain  under  the  orbit.  The  pain  lasted  from  three  to 
four  months,  attended  by  a  gradual  elevation  of  the  orbital  surface 
of  the  maxilla.  The  eye  above  this  surface  became  at  length  so 
aCFccted  as  entirely  to  lose  its  functions.  At  this  stage  of  the 
case  the  young  woman  was  directed  to  use  leeches  and  blisters  be- 
hind the  ears,  and  to  employ  drastic  purges.  After  three  months' 
blindness,  the  patient  first  perceived  a  discharge,  from  the  right  nasal 
fossa,  of  a  thick,  purulent  fluid.  This  discharge  had  existed,  he  says, 
ei"-hteen  months,  when  he  first  saw  the  case.  An  examination  of 
the  mouth  at  once  revealed  the  cause  of  so  much  misery,  and  the 
removal  of  three  roots,  in  a  state  of  periostitis,  was  the  simple 
means  by  which  two  most  important  organs  regained  their  proper 
functions. 

The  nasal  opening  of  the  maxillary  sinus,  it  is  known,  is,  in  a 
healthy  condition,  almost  closed  by  the  duplicature  of  membrane 
lining  the  turbinated  and  neighboring  bones  ;  congestion  of  this 
membrane  not  unfrequently  closes  it  entirely.  Thus  secretions  ac- 
cumulate, giving  alarming  and  threatening  disfigurements  to  the 
face.  The  weakest  points  in  the  osseous  boundaries  of  this  cavity 
are,  the  floor  of  the  orbit,  the  hard  palate,  the  tuberosity  of  the 
bone,  and  the  canine  fossa.  Any  accumulation  would  necessarily 
be  most  apt  to  vent  itself  at  one  of  these  four  points,  unless  atresia 
of  the  duplicated  membrane  alluded  to  should  occur,  and  which  is 
not  commonly  the  case. 

Note. — My  own  experience  regarding  abscess  of  the  antrum  is, 
that  in  the  great  majority  of  cases  the  pus  seeks  to  vent  itself 
through  the  floor  of  the  cavity.  After  the  inflammatory  action  has 
passed  to  the  suppurative  stage,  you  will  notice  a  swelling  in  the 
roof  of  the  mouth  at  the  side  of  the  mesial  line,  corresponding  to  the 
diseased  cavity :  this  is  the  abscess  pointing,  and,  if  left  to  itself, 
will  be  sure  to  make  an  ugly  opening.  Such  a  result  will  be  found 
particularly  undesirable  if  there  should  be  any  specific  virus  linger- 
ing in  the  system.  But  wherever  this  abscess  should  tend  to  point, 
it  is  of  course  desirable  to  abort  it. 

If  the  assertion  of  Harris  is  true,  concerning  the  almost  invariable 
dental  origin  of  this  abscess  (and  certainly  my  own  experience,  so 
far  as  it  goes,  confirms  him ;  for,  while  I  have  seen  several  cases  of 
this  kind,  I  have  yet  to  meet  with  one  w^here  the  treatment  indi- 
cated was  not  of  a  surgico-dental  character),  we  turn  naturally  to 
the  alveolar  arch,  seeking  there  the  source  of  offense  and  defense. 


ANOMALIES   OF  SECOND   DENTITION.  123 

For  a  single  momeut,  then,  let  me  direct  attention  to  a  few  dental 
lesions  of  the  most  practical  character,  and  without  the  ability  to 
recognize  which,  the  practitioner  will  assuredly  find  himself  at  sea. 

Because,  when  you  turn  to  this  dental  arch,  you  find  it  entirely 
clear  of  teeth,  and  healthy-looking,  you  are  not  hastily  to  conclude 
that  the  primary  lesion  is  not  in  such  direction.  You  are  to  re- 
member that  fangs  of  teeth  are  not  unfrequently  broken  oif  in  an 
attempted  extraction,  and  that  when  so  broken,  particularly  deep  in 
the  socket,  the  dentist  is  not  unapt  to  leave  such  pieces  alone.  Now 
it  is  easy  to  understand  that  a  fang  so  situated  may  be  the  source  of 
extensive  disease,  and  yet  the  gum  over  it  be  without  bi'eak  in  its 
continuity,  and  perfectly  healthy-looking.  The  rehition,  in  such  a 
case,  of  the  fang  is  with  the  antrum — it  need  necessarily  have  no 
external  sinus.  Make  here  an  explorative  incision  along  the  gum 
down  to  the  bone.  If,  happily,  you  come  to  a  cavity,  you  will  have 
hit  on  the  origin  of  the  trouble  ;  but  if  you  find  nothing,  you  have 
made  only  a  simple  incised  wound,  which  left  to  itself  will  generally 
heal  in  a  few  hours. 

Again,  because  the  part  may  have  its  usual  complement  of  teeth, 
and  each  tooth  should  seem  perfectly  healthy,  you  are  not  to  turn 
hastily  away.  There  may  be  in  one  of  these  teeth  a  dead  pulp.  To 
satisfy  yourself  on  this  point,  take  up  a  delicate  steel  instrument, 
and  strike  with  it  each  tooth  separately,  directing  your  patient  to 
note  any  difference  in  the  sensations ;  if  he  should  start  when  you 
strike  a  particular  tooth,  my  veracity  for  it,  you  have  found  the 
primary  lesion.  But  still  again,  the  lesion  may  be  here,  and  yet  the 
patient  not  express  the  anticipated  pain.  Take  now  a  hand-mirror, 
and  placing  your  patient  full  in  the  sunlight,  reflect  the  rays  over 
the  teeth, — if  there  is  a  dead  tooth,  you  will  remark  an  opacity  in  it 
not  belonging  to  its  neighbors :  this  is  the  tooth  ;  extract  it. 

If  a  tooth  has  a  plug  of  metal  in  it,  take  the  filling  out, — the 
cavity  will,  not  unlikely,  be  found  to  communicate  with  the  pulp 
chamber. 

If,  now,  for  a  few  moments,  we  study  periodontitis,  the  student 
will  be  prepared  to  make  the  most  of  the  cases  which  we  shall  have 
to  consider  under  various  heads  associated  with  such  lesions. 

Periodontitis  means  inflammation  of  the  periosteum  which  sur- 
rounds the  fang  of  the  tooth.  Its  causes  are  manifold :  scurvy, 
syphilis,  ptyalism,  a  dead  pulp,  direct  injury  to  the  part.  It  is 
sometimes  an  idiopathic  affection, — stomatitis  from  any  cause  may 
provoke  it,  simply  by  continuity  of  structure ;  it  is  very  common 


124  ORAL  DISEASES  AND  SURGERY. 

after  the  dentist  has  destroyed  the  pulp  of  a  tooth  and  filled  the 
fano-s  with  gold  or  other  metal.  A  common  cause,  as  remarked, 
is  an  overcrowded  condition  of  the  alveolar  arch. 

Periodontitis  commences  with  a  dull,  heavy,  gnawing  pain :  this 
is  the  state  of  simple  vascular  excitement  in  the  part.  As  the  grade 
of  inflammation  advances,  the  pain  increases  with  it,  the  tooth  seems 
to  project  beyond  its  fellows,  and  really  does  so ;  occlusion  of  the 
jaws  gives  agonizing  pain ;  finally,  if  not  arrested,  the  action  goes 
on  to  the  suppurative  condition,  yielding  alveolar  abscess.  Now, 
it  is  to  be  borne  in  mind  that  gum-boil  is  alveolar  abscess,  and  this  J 
is  the  way  in  which  the  pus  formed  commonly  vents  itself;  but,  " 
from  cases  hereafter  mentioned,  it  will  be  seen  that  so  simple  a 
thing  as  alveolar  abscess  may  utterly  confound  and  deceive  even 
very  experienced  men. 

Alveolar  abscess  almost  invariably  runs  into  a  chronic  condition. 
When  discharging  on  the  gum,  it  may  run  through  the  features  of 
gum-boil  once  a  week,  or  once  a  month,  for  years;  it  will  dischai'ge 
from  a  single  drop  to  a  spoonful  of  pus  per  day ;  will  be  one  day 
apparently  well,  and  the  next  in  full  discharge.  The  excruciating 
pain  referred  to,  pertains  almost  exclusively  to  the  original  inflam- 
matory attack,  although  the  tooth  continues  more  or  less  sore  until 
a  complete  cure  is  eftected.  The  inflamed  periosteum  of  one  tooth 
will  not  unfrequently  so  affect  surrounding  parts  that  a  patient  can- 
not possibly  locate  the  seat  of  pain.  (See  chapter  on  Trismus.) 

Diagnosis  and  Treatment. — The  afl"ected  tooth  will  always  re- 
spond to  a  stroke  from  a  steel  instrument,  whether  the  attack  is 
of  the  acute  or  chronic  form.  No  such  response  is  made  so  mark- 
edly in  any  other  form  of  odontalgia. 

A  periosteal  inflammation  may,  in  nine  out  of  twelve  cases,  be 
aborted  as  follows :  pass  a  lancet  several  times  through  the  gum 
down  to  the  alveolus ;  let  the  patient  hold  water  in  the  mouth  so  as 
to  prevent  the  formation  of  clot,  and  provoke  free  bleeding.  As 
soon  as  the  vessels  and  capillaries  have  disgorged  themselves,  paint 
the  parts  heavily  with  tinct.  of  iodine,  the  officinal  strength.  The 
philosophy  of  this  treatment  is  sufficiently  evident  not  to  need  ex- 
planation. 

Chronic  periosteal  inflammation  is  most  certainly  cured  by  extract- 
ing the  offending  tooth ;  when  this,  however,  seems  undesirable, 
inject  through  the  sinus,  which  passes  from  the  gum  into  the  cyst, 
at  the  root  of  the  tooth,  the  tinct.  of  iodine ;  do  this  for  three  or  four 
days,  and  tnen  force  through  the  sinus  a  tent  of  cotton.     Leave  this 


ANOMALIES   OF  SECOND   DENTITION.  125 

tent  to  nature ;  its  ejection  will  most  generally  be  found  to  be  the 
result  of  the  healthy  granulations  which  will  have  obliterated  the 
cyst. 

Anomaly  Seventh. — Germs  of  Heterogeneous  Development. — It 
occasionally,  indeed  frequently,  happens  that  the  dental  germ,  instead 
of  arranging  its  parts  according  to  the  ordinary  laws  of  its  nature, 
assumes  the  most  fantastic  and  heterogeneous  shapes,  giving  such  a 
variety  of  appearances  that  only  a  close  attention  could  appreciate 
its  dental  character.  Tumors  of  complex  kinds  are  thus  occasionally 
produced,  and,  unless  appreciated,  are  necessarily  the  source  of  much 
anxiety  both  to  surgeon  and  patient.  In  the  admirable  memoir  of 
M.  Forget,  crowned  at  the  Academy  of  Sciences,  Paris,  in  1859,  are 
illustrations  of  cases  both  of  this  seventh  and  the  ordinary  anomalies. 
I  present  them  to  my  readers  as  being  quite  as  satisfactory  studies 
as  perhaps  could  be  selected. 


126  ORAL  DISEASES  AND  SURGERY. 


PLATE    I. 

Fig.  1.— ft.  Osseous  tumor  united  to  a  molar  tooth  (a). 
Fig.  2.— a,  b.  Section  of  the  tooth  and  of  the  tumor. 

Fig.  3.— a,  b.  Dental  tumor  formed  by  the  anomalous  development  of  the 
first  two  molars, 
fl.  Summit  of  the  tumor,     b.  The  root  of  the  tumor. 
Fio.  4.— a.  Cyst  of  the  right  branch  of  the  inferior  maxillary  bone,  the 
cavity  of  which  is  made  visible  by  the  circumferential  resec- 
tion of  its  external  wall. 

b.  A  molar  tooth  inclosed  in  the  osseous  tissue,  and  e?i  relief  upon 

the  bottom  of  the  cyst. 

c.  External  wall  of  the  cyst,  inverted. 

d.  Condyle  and  neck  of  the  jaw. 

e.  Summit  of  the  coronoid  apophysis,  with  the  insertion  of  the  tem- 

poral muscle. 
Fig.  5. — Upper  jaw  of  a  horse;  view  of  half  of  the  palatine  face. 

a.  Osseous  cyst  developed  in  the  interior  and  right  side  of  the  jaw; 

it  includes  the  tumor  represented  by  Fig.  6. 

b.  Eight  canine,  thrust  backward  and  inward  toward  the  medio- 

palatine  line. 

d.  Alveolus  of  the  left  canine  tooth. 

e.  Osseous  perforation,  conducting  to  the  interior  of  the  cyst. 

Fig.  6. — Intramaxillary  osseous  tumor  (natural  size);  it  was  contained  in  the 
cyst  represented  in  Fig.  5. 

Fig.  7  (300  diameters). — Kepresents  a  part  of  the  section  of  the  tumor  shown 
in  Fig.  6.  This  tumor  appears  to  be  formed  entirely  of  the 
cement  or  osseous  substance  surrounding  the  dental  root.  It  is 
an  exostosis  of  the  dental  cement.  This  exhibits  the  structure 
described  in  the  explanation  of  Fig.  4,  Plate  I. 

a.  Vascular  canaliculi  of  the  osseous  substance  of  the  tumor  (Havers' 

glands).  The  tumor  traversed  by  these  as  in  the  normal  osse- 
ous substance — only  they  are  more  rare,  more  scattered,  and 
more  irregularly  distributed. 

b.  Osteoplasts  disposed  circularly,  or  nearlj'  so,  in  a  concentric  man- 

ner around  the  Haversian  canal,  but  less  exact  and  evident  than 
in  the  normal  condition. 

c.  The  osseous  substance,  properly  so  called,  in  which  the  osteoplasts, 

or  characteristic  cavities  of  the  osseous  tissue,  are  excavated. 


IFXiJ^TIB    I. 


F^i 


Us- 2 


(127) 


^^^j/^vD 


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N^^^lVi^       i^-7 


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(128) 


ANOMALIES   OF  SECOND   DENTITION.  129 


PLATE    II. 

YlQ.  1. — Eepresents  a  cyst  occupying  the  whole  extent  of  the  right  half  of  the 
body  of  the  lower  jaw,  and  of  the  coronoid  apophysis.  The  ex- 
ternal wall  of  the  cyst  has  been  removed,  and  permits  a  view  of 
the  cavity,  bounded  by  the  internal  wall  6,  which  remains. 

a.  The  wisdom  tooth,  developed  in  an  anomalous  fashion  in  the 
base  of  the  coronoid  apophysis. 

c.  Dental  canal,  open  through  the  whole  of  its  extent.  It  does  not 
communicate  with  the  cavity  situated  above  it. 

Fig.  2. — d.  Eight  side  of  the  inferior  jaw,  aifected  by  the  rarefying  osteite. 

a.  Large  molar  tooth  encysted  in  the  bone. 

b.  Interior  of  the  cyst,  with  a  black  bottom,  representing  the  mem- 

branous tissue  that  lined  its  surface. 

Fig.  3. — Same  cyst,  open  at  the  side  of  the  mouth.  It  reproduces  {a  and  b) 
the  aforesaid  anatomical  arrangements. 

Figs.  2  and  3. — c,  c.  Three  incisor  teeth,  the  canine  tooth  and  the  first  two 
molars,  removed  from  their  position,  and  retroverted  one  upon 
another. 


IPXj^TIE    XX. 


1?,0) 


IPHL-A^TE    XI. 


(131 


132  ORAL  DISEASES  AND  SURGERY. 


PLATE    III. 

ANOMALIES  IN   POSITION   OF   THE   TEETH. 

Fio.  1. — a.  Incisor  tooth  retroverted,  and  directed  toward  the  intramaxil- 
lary  symphysis. 

Fig.  2. — c.  Canine  tooth  developed  in  the  thick  part  of  the  floor  of  the  nasal 
fossae,  where  it  forms  a  prominence:  the  root  is  directed  for- 
ward. 

b,  b.  Section  of  the  maxillary  sinus. 

d.  Nasal  spine. 

a,  a.  Posterior  edge  of  the  nasal  fossas. 

Figs.  3  and  4. — Two  other  examples  of  anomalies  in  the  position  of  the 
teeth. 


(133) 


I'XjJ^TE     III. 


134  J 


ANOMALIES   OF  SECOND   DENTITION.  135 


PLATE    IV. 

Fig.  1. — a,  a.  Second  grinding  tooth  of  a  horse,  natural  size,  with  considera- 
ble development  of  the  roots,  transformed  into  two  spheroidal 
swellings. 

5,  h.  Portions  of  the  maxillary  bone  sheathed  in  the  tnmor,  and 
broken  in  its  extraction. 
c.  Orifice  conducting  to  the  interior  of  an  intradental  cavity. 
d,  d.  Circular  groove  corresponding  to  the  alveolar  arch,  and  form- 
ing a  sort  of  strangulation  between  the  tuberosity  a  and  the 
swelling  e,  which  is  underneath. 
/.  Inferior  surface  of  the  crown  of  the  tooth. 

Fig.  2. — Microscopic  examination  of  the  tumor  (300  diameters). — Kepresents 
part  of  a  thin  section  of  the  tumor  shown  in  Fig.  1.  The 
tumor  was  formed  jointly  by  a  hypertrophy  of  the  dental 
ivory  and  a  hypertrophy  or  exostosis  of  the  cement,  the  greatest 
part  being  formed  of  the  substance  of  the  cement. 

a,  b.  Kepresents  the  ivory  in  its  canaliculi — not  ramified  in  this 
section — and  terminating  near  the  union  of  the  ivory  and 
enamel. 

c,  d,  e.  Exhibits  the  mammillated  arrangement  seen  in  the  cement 
at  certain  points  of  the  surface  of  union  with  the  ivory  or 
dentine.  This  arrangement,  often  very  elegant  under  the 
microscope,  is  also  met  in  the  normal  teeth. 

ff,  h.  Osteoplasts,  or  characteristic  cavities  of  the  cement.  They  are 
especially  remarkable  for  their  size  in  all  the  preparations 
taken  from  this  piece. 
/.  Proper  substances  of  the  cement,  or  bone,  in  which  the  char- 
acteristic cavities  are  excavated.  It  is  here,  as  always,  homo- 
geneous; little  transparent,  except  when  it  is  reduced  to  very 
thin  laminae. 


:pi.jLTEi   i-v. 


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(130) 


b      b 


Fi$.i 


(137) 


138  OKAL  DISEASES  AND  SUBGEEF. 


PLATE    V. 

Fig.  1. — Intraniaxillary  bone  bearing  the  two  permanent  incisors  (a,  a) 
superposed,  and  exhibiting  an  anomalous  development.  The 
alveoli  of  the  same  infantile  teeth  are  partly  destroyed;  this  sec- 
tion formed  the  deposit. 

Fig.  2. — Tumor  of  the  ramus  of  the  inferior  maxillary  bone,  affected  with 
mollities  ossium.  At  the  surface  are  many  openings  of  encysted 
abscesses  ;  and  the  last  molar,  the  crown  of  which  extends  slightly 
beyond  the  alveolar  edges,  and  is  developed  in  the  thick  part  of 
the  base  of  the  coronoid  apophysis. 

Fig.  3. — Section  of  the  ramus,  showing  the  numerous  abscesses  that  exist 
throughout  its  whole  extent. 


I=IjJLTE    "V. 


E^.3 


( 133 ) 


CHAPTER    VII. 

THE   TEETH   AND   THEIR   DISEASES. 

ALVEOLAE  ABSCESS. 

Periodontitis  or  inflammation  of  the  alveolo-dental  periosteum 
(considered  in  the  previous  chapter),  when  not  successfully  com- 
bated, has  as  its  termination  alveolo-dental  abscess.  To  this  con- 
dition, as  a  distinct  one,  I  may  now  direct  attention. 

Alveolar  or  dental  abscess  is  of  course  the  history  of  an  inflam- 
mation and  suppuration  anywhere  in  the  body,  having  nothing 
peculiar  to  its  history,  except  as  such  peculiarities  associate  with 
the  anatomical  characteristics  and  influences  of  the  parts  involved. 
It  is  a  condition  in  which  a  tooth,  diseased  to  the  suppurative  point 
in  its  enveloping  membrane  or  periodonteum,  is  discharging,  through 
some  convenient  orifice  of  exit,  pus  secreted  by  or  formed  in  such 
membrane. 

The  local  features  of  such  an  abscess  may  be  described  in  a  very 
few  words.  At  the  apex,  or  somewhere  about  the  root  of  the  affected 
tooth,  a  degenerative  thickening  of  the  membrane  occurs,  the  old 
pyogenic  membrane.  This,  in  its  unhealthy  condition,  fails  to  or- 
ganize the  lymph  constantly  exuded  or  effused  by  it.  The  degene- 
ration of  this  lymph  is  pus.  As  such  membrane  grows  thicker  and 
thicker,  and  such  pus  accumulates,  it  becomes  evident  that  space 
and  vent  are  made  necessities ;  thus  absorption,  through  the  press- 
ure, is  secured,  and  the  matter,  sooner  or  later,  finds  egress,  giving 
generally  that  peculiar  fistule  in  the  gum,  called  parulis  or  gum- 
boil; the  most  vulnerable  wall  of  the  surrounding  osseous  parietes 
yielding  first,  thus  giving  the  direction  and  locating  the  fistule. 

The  formation,  and  confinement  of  pus,  in  a  cavity  so  obstinately 
closed  as  the  alveolus  of  a  tooth,  must  necessarily  inflict  the  severest 
suffering,  and  such  pain  is  so  constant  an  attendant  of  the  condition, 
and  is  of  such  almost  unbearable  character,  that  any  means  calcu- 
lated to  abort  or  limit  its  persistence  is  to  be  hailed  as  a  boon.  I 
take  it  for  gi'anted,  judging  from  observation,  that  it  is  the  severest 
(140) 


THE   TEETH  AND    THEIR   DISEASES.  141 

form  of  odontalgia.  The  condition  of  acute  pain,  however,  is  con- 
fined to  the  period  intervening  between  the  acute  inflammatory 
attacks  and  the  escape  of  the  pus,  the  period,  properly  speaking,  of 
periodontitis.  An  alveolar  abscess  fully  formed,  pain  is  limited  to 
soreness.  The  cure  of  the  perfected  alveolar  abscess  is  very  simple, 
at  least,  as  the  indications  are  concerned,  consisting  in  the  breaking 
up  of  the  cyst  and  sac,  and  exciting  an  action  of  sufiBciently  healthy 
character  to  fill  with  organizable  granulations  the  fistule. 

The  appreciation  of  the  treatment  of  alveolar  abscess,  begins  of 
course  with  the  treatment  of  the  acute  periodonteal  trouble,  of  which 
it  is  seen  to  be  simply  a  result.  This  was  considered  in  the  pre- 
vious chapter,  leaving  us  here  nothing  to  add,  except  that  if  such 
means  as  were  recommended  fail  in  securing  resolution,  the  more 
formidable  are  to  be  brought  into  requisition. 

As  periodontitis  is  so  frequently  aborted  by  scarifying  the  gums 
freely  and  deeply,  and,  after  the  congested  vessels  have  relieved 
themselves,  constringing  the  parts  by  applications  of  strong  tinct. 
of  iodine,  so  alveolar  abscess  can  very  frequently  be  aborted  by  the 
following  trifling  operation : 

With  a  sharp  scalpel  make  a  slight  cut  through  the  soft  parts  at 
the  apex  of  the  affected  tooth ;  next  take  up  a  spear-pointed  drill 
and  pierce  through  the  outer  plate  of  the  bone  into  the  cavity  in 
which  the  sac  is  being  developed,  break  up  this  sac,  and,  by  means 
of  a  delicate  tent,  keep  the  wound  patulous  for  a  few  hours. 

This  little  operation  is,  I  believe,  original  with  myself;  indeed,  I 
do  not  know  that  it  ever  has  been  performed  even  yet  by  any  one 
else;  but  I  am  well  assured,  through  a  pleasant  experience,  that  it 
very  commonly  spares  the  patient  upon  whom  it  is  practiced  days  of 
the  excruciating  torture  which  belongs  to  the  formative  stage  of  this 
disease.  The  philosophy  of  the  operation  will,  I  think,  be  at  once 
recognized. 

I  cannot  here  help  excepting  to  the  common  practice  of  ordering 
blisters  and  warm  fomentations  to  the  face  in  incipient  abscess ;  the 
practice  is  very  objectionable,  and  not  unfrequently  results  in  scars 
which  much  deform  the  patient.  If  the  practitioner  should  not 
desire  to  adopt  the  operative  suggestion  I  have  offered,  let  him 
order  a  roasted  fig  or  raisin  directly  to  the  affected  part ;  either  of 
these  will  do  equally  well  the  work  of  the  blister  or  poultice. 
Leeches,  general  blood-letting,  vigorous  antiphlogistic  medication, 
any  and  every  means  that  promises  any  good,  should  come  between 
the  periodontitis  and  the  abscess. 


142  ORAL  DISEASES  AND  SURGEBY. 

The  anomalies  of  alveolar  abscess,  if  such  a  term  might  be 
applied  to  conditions  not  at  all  infrequent,  may,  perhaps,  be  best 
studied  through  the  medium  of  examples.  I  select  a  few  from  my 
own  practice  and  that  of  others.  If,  happily,  they  may  serve  to 
throw  light  on  any  obscure  case  at  present  bothering  some  young 
practitioner,  I  shall  feel  well  repaid  for  the  trouble  of  collecting 
them. 

A  few  vears  ago  I  saw,  in  consultation  with  a  Dr.  B.,  of  this 

city,  Mrs. ,  who  had  been  afflicted  with  a  running  ulcer  at  the 

ape.x  of  the  chin  for  four  years.  During  this  period  the  lady  had 
been  under  the  care  of  some  five  or  six  different  practitioners,  and 
had  twice  been  operated  upon  for  supposed  disease  of  the  bone. 

Suggesting  that  the  origin  and  cause  of  this  fistule  might  be  found 
in  some  diseased  tooth,  I  was  assured  that  these  organs  had  beer 
most  carefully  examined,  and  that  there  was  not  an  unhealthy  tooth 
in  the  mouth. 

A  superficial  examination  seemed  to  verify  the  truth  of  the  as- 
surance. Not  satisfied,  however,  by  such  exajnination,  with  a  steel 
instrument  I  commenced  striking  each  tooth  separately ;  the  patient 
thought  that  in  the  left  inferior  lateral  incisor  she  experienced  a  sen- 
sation differing  from  that  of  the  others. 

Placing  her  now  in  the  full  sunlight,  I  reflected  the  rays  over  the 
teeth  by  means  of  a  hand-mirror ;  this  test  satisfied  me  that  the  in- 
cisor alluded  to  had  lost  its  pulp — it  showed  a  slight  opacity. 

I  was  now  convinced  that  the  disease  was  alveolar  abscess,  and 
predicated  on  my  examination  that  an  opening  made  into  the  affected 
tooth  would  discover  the  death  of  its  pulp ;  this  was  done,  and  the 
tooth  found  dead,  as  anticipated.  The  offending  organ  was  ex- 
tracted, some  necessary  local  attention  given  the  sinus,  and  the 
patient  was  well  in  a  week. 

Comment  on  this  case  scarcely  seems  necessary,  and  yet  it  may 
not  be  amiss  to  suggest  the  explanation  of  the  deceptively  healthy 
appearance  of  the  dead  tooth. 

When  the  pulp  of  a  tooth  dies,  discoloration  of  the  enamel  is  the 
common  result,  this  discoloration  being  caused  by  the  absorption  of 
the  dead  matter  by  the  tubules  of  which  the  dentine  is  made  up. 
Occasionally,  however,  the  opacity  is  so  slight  as  to  be  scarcely 

perceptible,  and  this  depends  on  the  dense  character  of  the  tooth 

not  unfrequently  the  tubules  being  so  occluded  as  to  destroy  their 
capillarity:  the  dead  pulp  is  not  therefore  taken  up.  A  very  vas- 
cular tooth,  having  a  dead  pulp  in  its  cavity,  will  soon  be  turned 
almost  black. 


THE   TEETH  AND    THEIR   DISEASES.  143 

A  dead  tooth,  however,  can  always  be  distinguished  by  the  tests 
which  I  have  given. 

The  pathology  of  .this  case  may  be  summed  up  very  briefly.  The 
death  of  the  pulp  provoked  periosteal  difficulty.  The  inflammation, 
uncombated,  resulted  in  alveolar  abscess.  The  pus,  after  inducing 
by  its  presence  the  absorption  of  the  bone,  dissected  its  way  under 
the  soft  parts  down  to  the  apex  of  the  chin,  where  it  discharged 
itself — the  abscess  passed  into  the  chronic  stage  ;  the  annoying  and 
formidable  fistulous  ulcer  was  of  course,  because  of  its  character, 
rendered  incapable  of  being  healed  by  an}'-  directly  local  treatment, 
or  that  not  addressed  to  the  true  seat  of  trouble. 

In  another  Consultation  saw  Miss  B ,  a  young  lady,  nineteen 

years  of  age.  In  this  patient,  a  fistule  in  the  very  center  of  her 
hard  palate  had  existed  for  some  two  years,  giving  rise  to  great 
uneasiness  (as  it  had  refused  to  yield  to  much  treatment),  a  cancer- 
ous cachexia  existing  in  the  family. 

The  denture  in  this  mouth  was  also  so  complete  as  not  to  have 
attracted  observation,  every  tooth  being  perfect,  with  the  exception 
of  a  single  molar,  which  tooth  had  a  small  filling  of  gold  on  its 
grinding  face.  The  filling  in  this  tooth  was  removed,  and  the  pulp 
found  dead.  Extraction  was  resorted  to,  and  in  three  or  four  days 
all  discharge  had  ceased.  On  the  sixth  day  the  patient  was  dis- 
missed cured. 

It  is  not  at  all  uncommon  to  find  the  sinus  of  an  alveolar  abscess 
venting  itself  somewhere  on  the  cheek.  This  is  too  frequently  the 
result  of  inviting  the  matter  to  the  surface  by  the  warm  applications 
made  to  the  side  of  the  face.  When  pus  thus  seeks  the  surface 
it  should  be  vented  from  the  inside.  The  operation  is  very  simple, 
and  will  be  successful  if  the  pus  should  have  found  its  way  even 
so  far  externally  as  to  have  but  the  skin  between  it  and  the  atmos- 
phere. Care  nmst,  however,  be  taken  not  to  wound  the  facial  artery 
or  the  duct  of  Steno. 

Abscesses,  associated  with  the  wisdom  teeth,  sometimes  vent  in 
the  parotid  region ;  in  these  cases  it  is  not  uncommon  to  find  the 
orifice  of  the  fistule  as  low  down  as  the  clavicle,  the  unyielding 
character  of  the  parotid  fascia — a  continuation,  as  it  will  be  remem- 
bered, of  the  deep  cervical — compelling  this  lengthened  dissection. 

Another,  and  indeed  very  curious  result  of  alveolar  abscess,  is  the 
formation  of  osseous  cysts  on  the  side  of  the  jaws ;  the  pus  instead 
of  inducing  the  ordinary  absorption,  is  provided  for  by  the  expansion 
of  the  outer  plate  of  the  bone.    These  cysts  give  no  sense  of  fluctua- 


144  ORAL  DISEASES  AND  SURGERY. 

tion  or  crackling  on  pressure;  there  is  no  appearance  of  surround- 
ing inflammation,  the  soft  parts  covering  them  do  not  differ,  in  any 
respect,  from  the  adjoining  tissue.  I  have  found  such  cysts  or  tumors 
generally  associated  with  teeth  in  which  the  pulps  have  been  de- 
stroyed and  the  fangs  filled  with  metal.  They  form  sometimes  very 
rapidly.  I  have  treated  them  where  the  cyst  has  enlarged  to  the 
si7.e  of  a  hickory-nut  in  a  single  week.  This  rapid  growth  is  par- 
ticularly diagnostic. 

The  easiest  treatment  is  of  course  the  extraction  of  the  offending 
tooth  ;  but  they  may  also  be  readily  cured  by  opening  them  trans- 
versely and  stuffing  the  cyst  with  lint,  saturated  with  tinct.  of 
iodine,  or  some  other  stimulant;  the  cyst  is  thus  obliterated,  and  the 
sac  at  the  end  of  the  fang  destroyed,  through  the  healthy  inflammar 
tion  which  the  treatment  excites. 

These  tumors  are  not  to  be  confounded  with  other  encysted 
tumors,  of  which  mention  will  hereafter  be  made. 

Mr.  Smith,  in  illustrating  a  lecture  on  alveolar  abscess,  notices 
the  following  cases  from  his  practice  : 

A  few  years  ago,  he  says,  a  middle-aged  man  asked  his  opinion  about 
a  fistulous  sore  which  opened  on  the  middle  of  his  whisker  of  the  right 
cheek.  Mr.  S.  introduced  a  probe,  and  finding  that  it  came  in  contact 
with  the  fang  of  the  last  molar  tooth  of  the  upper  jaw,  persuaded 
the  patient  to  allow  him  to  extract  it,  on  the  promise  that  he  should 
be  well  in  a  few  days.  On  the  tenth  day  the  gentleman  wrote,  by 
post,  to  say  that  the  discharge  ceased  the  day  the  tooth  was  extracted, 
and  that  at  the  time  of  writing  it  was  perfectly  well. 

He  relates  the  case  of  a  young  woman  who  came  under  his  charge 
at  the  infirmary,  with  a  fistulous  sore  in  the  fore  part  of  the  throat, 
within  an  inch  of  the  sternum.  It  had  been  discharging  upwards  of 
a  year.  On  probing  it,  the  instrument  could  be  passed  in  the  direc- 
tion of  the  molar  of  the  lower  jaw  on  the  left  side.  On  inquiry,  the 
patient  said  that  eighteen  months  before  she  had  a  tooth  drawn, 
but  the  fangs  had  been  left  in  the  jaw.  Afterward  an  abscess 
formed,  which  descended  lower  and  lower  until  it  burst  midway 
between  the  sternum  and  pomum  Adami.  Mr.  S.  extracted  the 
stump,  it  still  discharged  for  a  week,  when  it  got  well  without  other 
treatment. 

Mr.  S.  alludes  also  to  a  case  where  a  horse  had  been  condemned 
to  the  knacker's  yard,  as  being  afflicted  with  the  glanders,  having  a 
foul,  offensive  discharge  of  purulent  matter  from  the  nostrils,  and 
being  in  the  last  stage  of  emaciation.   A  veterinary  surgeon,  finding 


THE    TEETH  AND    THEIR   DISEASES.  145 

that  it  could  not  masticate  its  food,  examined  its  mouth,  and  detect- 
ing a  carious  tooth  in  the  upper  jaw,  extracted  it.  The  discharge 
ceased ;  the  horse  soon  began  to  thrive,  and  got  well. 

Mr.  Fleischman  {British  Medical  Journal)  relates  the  following 
example :  "  Miss  Rose  S  ,  a  little  girl,  aged  five  years,  had  been 
troubled  about  three  months  with  a  constant,  though  not  profuse, 
discharge  of  slightly-purulent  mucus  from  the  right  nostril ;  it  ap- 
peared to  be  the  sequel  of  a  cold.  The  mucous  membrane,  so  far  as 
it  could  be  examined,  was  healthy,  and  there  were  no  indications  of 
any  morbid  growth.  She  was  ordered  a  strong  injection  of  gallic  acid, 
and  took,  concurrently,  small  doses  of  the  sesquichloride  of  iron.  The 
only  advantage  she  derived  was  that  the  discharge  lost  its  purulent 
character ;  in  amount  it  remained  about  the  same,  though  the  treat- 
ment was  long  persevered  in  and  other  local  astringents  tried.  I 
suspected,"  says  Mr.  F.,  "there  must  be  some  undiscovered  local 
irritation.  Not  being  able,  on  careful  examination,  to  find  anything 
wrong  in  the  nasal  passages,  I  looked  to  the  condition  of  the  teeth, 
and  finding  the  right  upper  canine  carious,  removed  it.  The  dis- 
charge was  much  lessened  on  the  next  day,  and  in  the  course  of  a 
day  or  two  disappeared  altogether." 

Mr.  Fleischman,  although  he  does  not  see  that  his  case  is  simply 
one  of  alveolar  abscess, — but  offers  it  as  "  a  good  illustration  of  re- 
flected irritation," — truly  remarks  that  it  "  teaches  us  that  the  fons 
et  origo  mali  is  not  always  just  where  we  might  expect  to  find  it." 

I  have  had,  in  my  own  practice,  several  cases  where  the  pus  of 
an  alveolar  abscess  discharged  itself  from  the  nares;  but  the  dis- 
ease, in  evei'y  case  in  which  I  have  seen  it,  where  the  sinus  passed 
in  such  direction,  was  associated  with  the  central  incisor  teeth. 

Abscesses  of  this  nature  are  not  unfrequently  associated  with  the 
eruption  of  the  wisdom  teeth.  The  arch  being  too  small  to  accom. 
modate  the  advancing  organ,  it  becomes,  as  a  matter  of  necessity,  an 
agent  of  irritation  ;  inflammations  of  the  most  severe  nature  are  thus 
oftentimes  provoked,  inducing,  too  commonly,  trismus  and  abscess. 
(See  chapter  on  Trismus.)  Abscesses  from  this  cause  generally 
discharge  about  the  neck  of  the  tooth ;  they  may,  however,  void 
themselves  in  other  situations,  as,  for  example,  upon  the  face  or 
neck.  A  case  illustrative  comes  this  moment  to  my  mind: — Dr.  D., 
a  medical  gentleman,  suffered  for  some  time  with  heavy,  dull  pain 
in  the  right  half  of  his  lower  jaw,  and  which  was  attributed  to  two 
of  his  teeth,  much  decayed,  but  which,  however,  had  been  treated 
and  plugged.     Inflammation  of  a  severe  character  finally  developed, 

10 


146  ORAL   DISEASES  AND  SURGERY. 

and,  in  defiance  of  all  treatment,  ran  on  to  abscess,  which  abscess 
discharfred  upon  the  cheek.  The  pus  voided,  of  course  relief  was 
obtained.  The  sinus,  however,  continued  to  discharge,  and,  at 
the  time  of  my  being  consulted,  the  ulcer  had  become  a  source  of 
much  annoyance  as  well  as  deformity.  This  case  had  been  exam- 
ined by  various  friends  of  the  gentleman,  and  while  all  pronounced 
it  alveolar  abscess,  all  associated  it  with  the  treated  teeth.  The 
removal  of  a  developing  wisdom  tooth,  a  single  cusp  alone  of  which 
presented,  caused  the  fistule  to  heal  in  a  single  week.  (See  chapter 
on  Odontalgia.) 


CHAPTER    VIII. 


THE    TEETH   AND   THEIR   DISEASES. 


TEISMUS. 

In  the  chapter  on  Dental  Anomalies,  I  alluded  to  the  process  of 
maxillary  enlargement,  and  exhibited  how  that  process  was,  in  part, 
counterbalanced  by  an  untimely  extraction  of  the  deciduous  teeth. 
I  further  showed  how  certain  derangements  of  the  dental  organs 
were  a  common,  if  not  a  necessary,  sequence  to  such  abridgment  of 
the  arch ;  and,  among  other  ill  effects,  referred  to  the  impossibility 
of  a  natural  and  healthy  evolution  of  the  wisdom  teeth,  and  to  the 
conditions  favoring  periodontal  inflammation. 

In  this  chapter  we  are  to  consider  lock-jaw  entirely,  as  it  has  a 
local  signification,  and  even,  so  far  at  least  as  a  few  paragraphs  are 
concerned,  more  exclusively  than  this,  as  it  has  alone  a  surgico- 
dental  signification. 

Such  surgico-dental  signification,  however,  will,  I  apprehend, 
outside  of  tetanic  conditions,  be  found  to  have  the  widest  relation- 
ship to  the  lesion,  and,  indeed,  if  my  experience  has  not  been  un- 
commonly one-sided,  it  will  be  found  to  have  the  very  closest  rela- 
tionship ;  for,  I  incline  to  think,  that  in  every  twenty  cases  of  local 
trismus,  eighteen  has,  as  the  primary  lesion,  periodontitis  in  some 
of  its  varied  forms. 

We  have  considered  the  retraction  of  the  dental  arch.  We  will 
now  look  at  such  lesions  as  this  retraction  has  engendered — lesions 
pertaining  to  the  subject  we  have  now  under  consideration. 

The  troubles  of  an  individual  afflicted  with  a  contracted  dental 
arch  are  most  apt  to  begin  at  about  the  fifteenth  or  sixteenth  year  of 
age.  If  you  look  into  such  a  mouth  you  will  find  the  teeth  crowded 
together  in  most  uncomfortable-looking  positions.  The  last  molar 
of  the  lower  jaw  you  will  see,  most  likely,  jammed  into  the  ramus ; 
while  the  same  tooth  of  the  superior  jaw  will  be  found  occupying 
the  very  extreme  of  the  tuberosity  of  the  bone. 

At  this  period — unless,  fortunately,  the  teeth  are  possessed  of  un- 

(HY) 


148  ORAL   DISEASES  AND  SURGERY. 

common  resistance— jou  will  find  them  breaking  down  from  approx- 
imal  caries ;  while,  as  the  result  of  such  caries,  combined  with  the 
crowded  condition  of  the  fangs,  the  alveolo-dental  periosteum  enters 
into  the  subinflammatory  state,  and  becomes  as  ready  to  put  on 
acute  disease  as  is  the  tinder  to  take  the  spark. 

If,  then,  interference  with  the  elongatory  process  has  been  such 
as  to  yield  these  troubles,  when  only  twenty-eight  teeth  have 
erupted,  is  it  not  plain  to  infer  that  the  development  of  the  four 
dentes  sapientiae  must  proportionably  add  to  these  difficulties  ?  Of 
course  it  is  very  plain,  and  only  by  appreciating  the  character  of 
such  trouble  can  we  fit  ourselves  to  abort  its  lesions. 

These  lesions  are  periostitis,  alveolar  abscess,  stomatitis,  ostitis, 
necrosis,  trismus,  etc. 

In  the  chapter  on  Anomalies,  I  remarked  that  all  dental  troubles 
arising  from  retraction  and  diminution  of  the  maxillary  arch  could 
be  provided  against  by  a  timely  extraction  of  certain  of  the  perma- 
nent teeth ;  and  from  this  we  might  infer  that  trouble  arising  from 
an  advancing  wisdom  tooth  might  also  be  provided  for  on  the  same 
principle,  namely,  by  extracting  the  second  molar,  thus  providing 
the  required  alveolus. 

These  pathological  conditions,  and  the  remedial  and  prophylactic 
indications  so  plainly  written  over  them,  it  would  seem  impossible, 
because  of  their  very  simplicity,  to  overlook ;  that  they  are  over- 
looked, however,  is  too  evident,  from  their  many  secondary  lesions 
which  the  surgeon  finds  himself  constantly  called  upon  to  treat. 

I  advanced  the  view  that  the  majority  of  the  cases  of  trismus 
would  be  found  having,  as  the  primary  lesion,  some  periodontal 
trouble.  Of  course  I  would  be  understood  as  not  including  trismus 
neonatorum,  or  any  trismus  traumaticus,  the  lesion  of  which  was 
self-evident.  A  child  might  get  a  severe  burn  on  the  cheek,  and 
trismus  be  the  result  of  the  inodular  tissue,  which  would  close  up 
the  break  in  the  continuity.  Anchylosis  might  exist,  the  sequence 
to  articular  disease.  Traumatic  tetanus,  affecting  the  muscles  of 
the  jaw,  would  have  a  primary  lesion  combined  with  peculiar  nerv- 
ous disturbances,  which  would  give  the  diagnosis  But  it  is  to  the 
numberless  cases  of  so-called  idiopathic  trismus  I  allude,  and  to 
the  cases  of  trismus  which  have  evidently  alone  a  local  significa- 
tion; that  signification  not  being  always  very  evident,  or  other- 
wise associated  with  so  many  complications  as  not  to  seem  di&-j 
tinguishable. 

We  read  in  reports  of  case  after  case  of  local  trismus,— of  the 


THE    TEETH  AND    THEIR   DISEASES.  149 

lesion  being  referred  to  this  cause  and  the  other  cause, — the  treat- 
ments being  as  various  as  the  diagnoses.  Many  of  the  inferences 
thus  presented  are,  without  doubt,  just  and  reliable ;  but  I  would 
give  it  as  my  experience  that  where,  personally,  I  have  had  the 
opportunity  of  seeing  such  cases  as  would  seem  to  be  their  parallel, 
I  have  mostly  been  able  to  point  out  to  the  practitioner  exhibiting 
the  case,  as  the  primary  lesion,  some  dental  disturbance,  simple  or 
obscure. 

In  the  epitome  of  Braithwaite,  page  191,  vol.  ii.,  is  a  case,  the 
diagnosis  and  treatment  of  which  will  serve  as  an  example.  Dr. 
Sellers,  the  practitioner  who  reports  it,  ascribes  the  trismus  to  a 
complication  of  inflammatory  and  nervous  derangements.  Now, 
while  I  might  have  found  myself  wrong,  yet  from  the  history,  and 
from  the  age  of  his  patient,  I  should  have  expected,  had  I  seen  the 
case  with  him,  to  have  been  able  to  have  pointed  out  that  the 
ulcerated  sore  throat,  to  which  he  alludes,  had  its  primary  in  a 
periosteal  trouble  of  the  alveolo-dental  membrane ;  let  the  reader, 
however,  draw  his  own  inference.  I  will  compare  with  this  case 
one  from  my  own  practice. 

Dr.  Sellers'  C asy,.— Acupuncture  in  Protracted  Lock-jaw. — The 
patient,  twenty-five  years  of  age,  unmarried,  had  for  years  been  sub- 
ject to  attacks  of  suppurating  sore  throat,  in  which  the  jaws  often 
became  nearly  immovable  for  two  or  three  days  before  the  discharge 
of  matter.  In  1826,  she  had  a  severe  attack,  from  which  resulted 
complete  lock-jaw,  accompanied  with  hysterical  symptoms,  which 
attack  yielded,  after  six  weeks  of  treatment,  so  far  that  she  could  put 
a  teaspoon  in  her  mouth.  After  nearly  a  year,  the  jaw  again  be- 
came completely  fixed,  without  accompanying  sore  throat,  and  the 
same  treatment,  with  galvanism,  was  tried  without  effect.  Although 
unequivocally  connected  with  hysteria,  there  was  reason  to  think, 
from  the  inflammatory  action  with  which  the  disease  set  in,  that 
the  affection  was  not  purely  spasmodic,  but  was  kept  up  by  the 
rigidity  of  the  muscles  closing  the  jaw  produced  by  inflammation  ; 
in  consequence  of  which  the  antagonistic  muscles  had  become  in- 
adequate to  the  effort  of  opening  the  mouth  under  the  mere  influence 
of  volition. 

It  was  this  view  of  the  case  which  made  Dr.  Sellers  think  it 
more  reasonable,  in  making  trial  of  the  needles,  to  insert  them 
into  the  muscles  opening  the  jaw,  in  the  expectation  of  exciting 
them  to  such  a  contraction  as  might  overcome  the  rigidity  of  their 
antagonists. 


150  ORAL  DISEASES  AND   SURGERY. 

On  each  of  the  two  following  days  two  needles  were  inserted, 
one  on  each  side  of  the  mesial  line  between  the  chin  and  the  hyoid 
bone,  the  effect  being  short,  convulsive  efforts.  The  teeth  began  to 
grate  on  each  other,  and  the  jaw  was  drawn  from  side  to  side,  not 
by  single  alternate  contractions,  but  by  severe  convulsive  move- 
ments on  one  side,  followed  by  a  nearly  equal  number  toward  the 
other  side,  interrupted  occasionally  by  a  momentary  opening  of  the 
mouth  to  the  extent  of  about  two  fingers'-breadth. 

The  convulsions  continued  after  the  needles  were  withdrawn ; 
ceased  and  became  renewed  again  after  a  few  minutes,  and  returned 
spontaneously  in  the  evening  on  both  occasions.  Some  increase  of 
voluntary  power  over  the  jaw  followed  both  applications  of  the 
remedy.  After  each  trial  of  the  acupuncture  some  improvement 
was  observable ;  but,  as  the  spontaneous  convulsion  was  almost 
always  followed  by  a  slight  loss  of  motion,  the  progress  made  was 
slow. 

The  needles  were  usually  inserted  to  the  depth  of  half  an  inch, 
and  sometimes  to  the  depth  of  an  inch. 

The  acupuncture,  together  with  leeches,  was  used  for  ten  days, 
by  which  time  the  patient  could  open  the  mouth  two  fingers'- 
breadth  and  chew  soft  substances.  She  then  went  into  the  country 
for  five  weeks,  by  which  she  derived  great  benefit ;  but,  being  ex- 
posed to  cold  and  wet  on  her  return,  had  another  severe  attack,  the 
consequence  of  which  was  the  loss  of  much  of  the  voluntary  power 
over  the  muscles  of  the  jaw.  The  needles  were  again  resorted  to 
with  the  same  effects  as  before  ;  but  the  pain  produced  by  the  con- 
vulsions was  greater,  and  lasted  longer,  while  the  spontaneous 
convulsion  recurred  several  times  in  the  evenings  after  each  of  the 
first  trials.  As  leeching  did  not  succeed  in  mitigating  the  con- 
vulsion, the  temporal  artery  was  opened  with  the  desired  result, 
and  with  the  effect  at  the  same  time  of  restoring,  to  a  considerable 
extent,  the  sight  of  the  right  eye,  which  she  almost  lost  with  the 
first  attack  of  lock-jaw.  A  second  detraction  of  blood  from  the  same 
vessel  diminished  the  force  of  the  convulsion  so  much  as  to  permit 
the  acupuncture  to  be  used  twice  a  day.  Nine  days  after  the  re- 
newal of  the  operation,  the  jaw  had  recovered  its  natural  extent  of 
motion. 

The  aphonia,  which  had  come  on  at  the  same  time  as  the  affec- 
tion of  the  eye,  was  completely  cured  by  a  smart  shock  of  elec- 
tricity. 

The  case  I  referred  to,  as  from  my  own  experience,  occurred  in 


THE   TEETH  AND    THEIR   DISEASES.  151 

the  practice  of  a  friend, — my  relation  with  it  being  in  a  consultation. 
Its  history  is  as  follows  : 

For  a  period  of  several  years  the  patient,  Mary  C,  twenty-four 
years  of  age,  had  been  troubled  with  attacks  of  sore  mouth  and 
throat  whenever  she  unduly  exposed  herself;  these  attacks  had 
always  associated  with  them  partial  loss  of  voice  and  general  ex- 
citation of  her  whole  nervous  system,  while  her  jaws  were  invaria- 
bly stiffened  to  a  greater  or  less  extent,  according  to  the  severity  of 
the  attack. 

On  each  of  these  occasions  she  had  depended  for  relief  upon 
domestic  treatment  or  homoeopathy.  At  the  period,  however,  of  her 
coming  under  the  care  of  my  friend.  Dr.  W.,  she  was  suffering  from 
such  severe  trouble  as  to  decide  her  usual  attendant  into  dismissing 
the  case.  Her  jaw  had  remained  so  firmly  locked  for  a  period  of  six 
weeks  that  it  was  with  difficulty  a  knife-blade  could  be  introduced 
between  the  teeth.  This  particular  spell  had  come  on  as  usual ; 
but  the  patient  said  there  was  something  about  it  which  made  her 
think  that  her  teeth  were  implicated  ;  she  could  not  say  what  tooth 
or  teeth,  but  thought  it  was  one  or  more  in  the  lower  jaw. 

Now,  whatever  was  to  be  discovered  as  the  primary  lesion  in  the 
case,  its  surgical  feature,  as  it  presented  itself  to  our  attention, 
was  an  extra-capsular  mass  of  coagulated  lymph  about  the  tempero- 
maxillary  articulation,  which  overbalanced  the  influence  of  the  de- 
pressor muscles,  holding  of  course  the  parts  in  a  state  of  false 
anchylosis. 

I  asked  the  patient  "  if,  when  these  attacks  came  on,  her  face  had 
not  always  swelled  more  or  less?"  She  said  that  "it  had."  I 
asked  her  "  if  the  cheek  had  not  always  a  stiff,  hard  feeling  in  it, 
which  wore  away  gradually  after  such  attacks?"  "It  was  so," 
she  told  me. 

Dr.  W.,  agreeing  with  me  that  the  speediest  way  of  overcoming 
the  trismus  was  by  mechanically  breaking  up  the  adhesions,  I  pro- 
cured a  pine  stick  about  a  foot  in  length,  tapering,  wedge-shape, 
from  an  inch  and  a  half  base.  The  thinnest  portion  of  this  wedge 
was,  after  much  trouble,  passed  between  and  across  the  dental 
arches,  and,  after  being  forced  a  little  further  on,  the  stick  was 
turned  on  its  axis,  the  adhesions  yielding  before  the  strain.  Thus 
the  mouth  was  opened  at  least  an  inch,  and  we  were  enabled  to 
explore  this  cavity  for  the  lesion  upon  which  the  trouble  depended. 

So  far  this  case  will  be  seen  closely  to  similate  that  of  Dr.  Sellers 
— sore  throat,  aphonia,  hysteria. 


152  ORAL  DISEASES  AND  SURGERY. 

Now,  here  we  found  all  the  trouble  emanating  from  a  wisdom 
tooth  projecting,  as  it  were,  from  the  very  angle  of  the  jaw,  and 
half  covered  in  by  an  operculum  of  gum  drooping  over  on  it  from 
the  ramus.  The  tooth  of  course  we  at  once  removed.  We  dis- 
missed the  patient  for  the  day,  after  directing  a  sorbefacient  external 
application. 

The  next  afternoon,  at  four  o'clock — no  inflammation  having  super- 
vened— we  completed,  by  our  mechanical  appliance,  the  unlocking 
of  the  jaw.  In  a  week  the  patient  was  dismissed  well.  She  has 
since  had  no  return  of  her  spells,  and  I  am  perfectly  sure  will  not 
have. 

I  think  a  parallelism  between  these  two  cases  will  be  recognized, 
but  should  the  reader  disagree  with  me,  the  study  of  them  Mall  not, 
I  trust,  be  without  its  profit. 

One  of  the  most  severe  cases  of  inflammation  of  the  mouth,  throat, 
and  face,  combined  with  a  bad  trismus,  I  have  ever  seen,  was  in  the 
person  of  a  medical  student  in  the  office  of  a  Dr.  C,  of  this  city — 
the  primary  lesion  being  such  a  half-erupted  wisdom  tooth  as  I 
have  alluded  to  as  being  found  in  the  preceding  case.  This  patient, 
when  I  first  saw  him,  had  been  suffering  for  two  or  three  weeks. 
The  operculum  of  gum  had  been  split  up  on  two  different  occasions. 
Antiphlogistics  in  every  form  had  been  resorted  to.  The  patient 
came  to  me  under  the  anticipation  that  nothing  could  save  him 
from  necrosis  of  the  angle  of  the  bone. 

I  gave  this  man  one  and  a  half  pounds  of  ether ;  it  seemed  im- 
possible to  get  him  into  an  anaesthetic  condition,  his  physical  suffer- 
ing was  so  great.  Prying  his  mouth  open,  just  sufficient  to  introduce 
the  key  of  Garengeot,  I  extracted,  with  much  difficulty,  the  offending 
tooth.     In  three  days  he  was  again  attending  to  his  studies. 

This  peculiar  lesion  of  a  half-erupted  wisdom  tooth  may  well 
claim  a  moment's  attention.  Many  a  practitioner  has  been  so 
deceived  by  the  anomaly  as  to  have  been  led  widely  astray  in  the 
study  of  his  cases. 

Where  this  condition  exists,  you  will  notice,  by  looking  into  the' 
mouth,  that  only  the  anterior  face  of  the  tooth  has  fairly  erupted, 
the  other  two-thirds  being  overlaid  by  the  integuments  of  the  ramus. 
You  infer  that  the  development  is  not  yet  perfected,  and  conse- 
quently it  does  not  even  strike  you  to  associate  disease  with  the 
parts ;  but  this  tooth,  a  single  cusp  of  which  only  is  through  the 
gum,  may  have  caries  extending  into  its  pulp-cavity,  or  may  be  the 
seat  of  the  most  aggravated  periodontitis.     It  is  the  common  im- 


THE    TEETH  AND    THEIR   DISEASES.  153 

pression  that  wisdom  teeth  decay  early ;  that  they  are  not  a  sub- 
stantial class  of  teeth.  The  fact  is  that  four-fifths  of.  the  wisdom 
teeth  which  decay  so  early,  have  been  destroyed  by  this  operculum 
of  gum.  The  explanation  is  very  evident.  The  decomposing  epi- 
thelial scales,  and  other  debris  of  the  mouth,  combine  in  the  acidity 
of  their  reaction  to  irritate  the  bony  structure  of  the  tooth,  thus 
quickly  destroying  its  integrity.  I  am  sure  that  I  have  seen  more 
than  a  thousand  cases  illustrative  of  this  fact ;  and  if  any  practi- 
tioner will  take  the  trouble  to  dissect  off  this  fleshy  lid — the  proper 
treatment,  by-the-way — and  examine  with  a  delicate  probe  the  sulci 
of  the  tooth,  in  nine  cases  out  of  twelve  he  will  find  caries. 

Such  a  lesion  will  at  once  be  recognized  to  have  important  surgi- 
cal relations.  For  example,  I  have  b&en  consulted  time  and  again 
by  persons  who  have  been  sufferers  for  a  considerable  period  from 
what  has  been  pronounced  and  treated  as  neuralgia.  Their  teeth 
had  not  escaped  observation,  but  had  been  examined  and  pro- 
nounced sound.  I  have  found  in  such  mouths  not  unfrequently  this 
operculum  of  gum  overlying  the  wisdom  tooth.  This  I  have  dis- 
sected off,  exposing  compound  caries.  I  have  extracted  such  teeth, 
and  the  patients  have  been  instantly  relieved  of  their  neuro-odon- 
talgia. 

Again ;  these  fleshy  cups,  catching  and  holding,  in  contact  with  the 
soft  parts,  insoluble  particles,  as  often  found  mixed  with  the  food, 
will  provoke  periostitis,  or  even  ostitis  of  the  angle  and  ramus  of 
the  jaw.  I  have  seen  the  most  alarming  inflammatory  attacks  thus 
provoked.  The  tooth  in  these  cases,  as  I  have  somewhere  else  re- 
marked, will  alway  respond  to  the  stroke  of  an  instrument.  Its 
periosteum  being  inflamed,  common  sense  would  direct  that  a  tooth 
so  diseased  should,  be  at  once  extracted ;  but  such  extraction  is  oc- 
casionally among  the  almost  impossible  things.  A  tooth  so  affected 
will  not  unfrequently  have  but  a  point  erupted  not  larger  than  the 
head  of  a  pin.  In  these  cases  the  best  thing  that  can  be  done  is  to 
extract  the  adjoining  molar  ;  this  relieves  the  pressure  on  the  ramus 
of  the  jaw,  and  gives  room  for  the  posterior  tooth.  It  will  commonly 
yield  a  cure. 

Trismus  depending  on  such  lesions  is  not  unfrequently  the  only 
external  evidence  yielded  by  the  inflammatory  attack.  The  jaw 
stiffens  and  relaxes,  as  an  odontalgia  will  come  and  go.  In  such 
ephemeral  cases  it  is  not  at  all  unlikely  that  the  trismus  is  exclu- 
sively a  nervous  action,  or  reflected  irritation  to  the  motor  branch  of 
the  trifacial, — slight  local  inflammatory  action  being  the  irritant. 


154  ORAL   DISEASES  AND  SURGERY. 

Wisdom  teeth  erupt  from  the  seventeenth  to  the  thirty-fifth  year ; 
generally,  however,  at  about  the  twentieth  year. 

Some  years  ago  I  treated  a  case  of  trismus,  the  history  of  which 
is  as  follows : 

The  patient,  David  B.,  a  farmer,  after  doing  a  hard  day's  work, 
and  getting  himself  much  overheated,  threw  himself,  just  at  early 
evening,  down  in  a  cool  outhouse  to  rest.  Here  he  fell  asleep,  not 
waking  until  near  midnight.  The  next  day  he  felt  a  soreness  in  the  left 
superior  alveolar  arch,  which  soreness  increased  for  two  or  three  days ; 
after  which  it  deserted  the  teeth  and  passed  to  the  antrum.  Then 
commenced  a  swelling  in  the  integuments  of  the  face,  which  advanced 
until  it  shut  up  completely  the  left  eye.  The  jaws  began  to  stiffen, 
and  ended,  after  three  or  four  days  more,  in  complete  immobility. 

I  was  called  to  the  case,  after  the  lock-jaw  had  existed  nine  weeks, 
the  patient  having  barely  been  able  to  support  life  by  putting  his 
mouth  into  a  basin  filled  with  soup,  and  sucking  the  nutriment 
through  his  teeth.  During  this  time  he  had  been  seen  by  seven 
different  practitioners,  no  one  of  whom  had  seemed  to  appreciate  his 
case,  or  what  perhaps  is  more  probable,  none  of  whom  had  been 
willing  to  assume  the  trouble  of  it.  The  patient  had  never  told  any 
of  these  gentlemen  about  the  soreness  first  felt  in  his  teeth,  and  no 
one  of  them  had  ever  questioned  him  in  this  direction ;  his  single 
complaint  was  of  a  great  weight  about  his  cheek. 

The  diagnosis  of  the  case  was,  primarily,  periodontitis;  this  in- 
flammation, by  a  double  continuity  of  structure,  had  extended  into 
the  maxillary  sinus,  and  to  the  integuments  of  the  face.  The  inflam- 
mation of  the  antrum  had  been  sufficiently  severe  to  have  resulted 
in  abscess  ;  abscess  of  the  alveolo-dental  membrane,  or  of  the  lining 
membrane  of  the  cavity.  The  inflammation  of  the  face  had  resulted 
in  the  exudation  of  lymph,  which  lymph  in  a  state  of  coagulation 
was  the  cause  of  the  trismus. 

A  first  effort  was  directed  to  getting  into  the  antrum,  which  I  felt 
well  assured  was  filled  with  pus.  This  was  done  by  prying  out  the 
second  molar  tooth  with  an  elevator,  pushing  it  into  the  mouth 
(from  which,  with  some  trouble,  it  was  afterward  gotten  out);  the 
extraction  was  followed  by  profuse  discharge.  The  patient  described 
the  relief  as  being  immense. 

1  removed  this  particular  tooth,  not  because  it  was  more  carious 
than  its  fellows,  but  because  it  was  somewhat  loose,  and  thus  gave 
evidence  of  the  diseased  condition  of  its  periosteum.  Again,  it  is 
through  the  alveolus  of  the  palatine  fang  of  this  tooth  that  we  find 


THE    TEETH  AND    THEIR   DISEASES.  155 

our  easiest  and  best  road  to  the  antrum ;  in  this  case,  as  is  seen, 
the  fang  communicated  with  the  cavity. 

On  the  day  succeeding  the  evacuation  of  the  abscess,  the  patient 
expressed  himself  as  entirely  free  from  pain,  his  only  trouble  being 
the  trismus,  which  had  not,  as  yet,  relaxed  in  the  least. 

To  the  touch,  all  the  parts  about  the  articular  extremity  of  the 
inferior  maxilla  seemed  completely  indurated.  I  hesitated  to  at- 
tempt the  breaking  up  of  the  parts  mechanically,  fearing  that  thereby 
I  might  do  injury  to  the  important  vessels  which  are  associated  with 
the  head  of  this  bone, — the  internal  carotid,  and  internal  maxillary 
arteries.  The  induration  was  of  course  extra-capsular,  and  was  of 
sufficient  extent  to  have  bound  the  jaw  from  the  glenoid  cavity  to 
the  anterior  border  of  the  masseter  muscle  ;  passive  motion  was  re- 
sorted to,  but  employed  very  gently.  Leeches,  blisters,  and  sorbe- 
facients  were  depended  on, — the  case  progressed  very  slowly,  the 
patient  having  to  come  to  my  office  every  day  for  fifteen  days ;  at 
the  end  of  this  time,  but  after  removing  other  diseased  teeth  from  his 
mouth,  he  was  dismissed  cured. 

When  one  is  called  to  a  case  of  trismus  of  any  standing,  the 
anchylosis  being  the  result  of  inflammatory  action,  questions  may 
arise  as  to  the  propriety  of  mechanically  breaking  up  the  adhesions. 
The  condyloid  extremity  of  the  maxillary  bone  is  assuredly  not 
the  stanchest  part  of  the  body,  and  there  are  anatomical  relations 
which  it  would  not  be  at  all  pleasant  to  disturb, — these  things  are 
for  the  surgeon  to  decide  upon.  So  far  as  I,  individually,  am  con- 
cerned, I  now  use  mechanical  force  in  all  cases  that  come  under  my 
care,  premising  of  course  that  the  case  is  one,  where,  from  inflam- 
mation, the  trismus  depends  on  effused  lymph.  I  am  willing  to  run 
the  risk  for  the  great  and  immediate  good  yielded  ;  some  considera- 
ble experience  in  this  direction  assuring  me  that  the  risk  is  materi- 
ally influenced  by  the  manipulations.  Of  course  I  do  not  mean  to 
recommend  that  attempt  should  be  made  to  open  the  mouth  to  its 
greatest  capacity  with  a  single  turn  of  the  lever  employed,  although 
there  are  cases  where  such  practice  would  be  very  commendable.  I 
have  so  opened  the  mouth  many  a  time,  but  not  in  cases  of  long 
standing.  Generally,  the  force  should  be  applied  with  gentleness, 
gain  a  little  one  day,  and  a  little  the  next ;  it  takes  but  a  very  short 
time  to  open  a  mouth  in  this  way;  besides,  if  your  force  is  applied 
with  such  judgment  as  not  to  provoke  inflammation,  you  will  arouse 
to  co-operation  the  absorbent  system,  the  excitement  acting  as  a 
stimulus  to  it,  and  it  will  be  found  to  do  its  part  vigorously. 


156  ORAL  DISEASES  AND   SURGERY. 

A  person  will  not  unfrequently  be  attacked  with  trismus  after  the 
dental  operation  of  inserting  a  pivot  tooth.  Here  the  lesion  is  in- 
flammation, and  the  treatment  is  to  be  directed  accordingly;  the 
root  of  the  tooth  is  in  a  state  of  periodontitis. 

A  person  will  sometimes  be  attacked  with  trismus  after  the  opera- 
tion of  plugging  a  tooth  with  metal;  the  attack  comes  on  suddenly; 
it  is  a  reflex  nervous  action.  The  conducting  facility  of  the  metal 
irritates  the  nerve  periphery  in  the  pulp ;  this  irritation  is  referred 
to  the  Gasserian  ganglion,  and  thence  reflected  to  the  muscles  of 
mastication.  To  prove  the  existence  of  this  lesion,  direct  the  patient 
to  hold  cold  water  in  contact  with  the  tooth. 

To  treat  a  case  of  this  kind,  remove  the  metal ;  when  the  irrita- 
tion has  subsided,  advise  that  before  refilling  a  non-conducting  sub- 
stance shall  be  placed  between  the  plug  and  the  floor  of  the  cavity; 
or,  because  of  the  thinness  of  the  bony  septum,  it  may  be  desirable 
to  destroy  the  pulp. 

Spasmodic  trismus,  very  obscure,  may  result  from  the  employ- 
ment of  two  different  metals  in  the  operation  of  tooth  plugging: 
galvanic  action  is  the  consequence,  and  the  nerve  is  subjected  to  a 
most  harassing  irritation.  To  test  for  this  trouble,  increase  the 
action  by  holding  silver  and  zinc  against  the  plug.  This  test,  how- 
ever, will  irritate  any  pulp  into  a  state  of  excitement,  and  is  an 
admirable  search  warrant  for  obscure  lesions  of  the  organ.  The 
treatment  consists  of  course  in  the  removal  of  the  plug,  and  the 
medication,  if  required,  of  the  irritated  pulp. 

So  I  might  extend  over  many  pages  the  consideration  of  dental 
lesions  in  connection  with  trismus.  I  have,  however,  written 
enough,  I  presume,  to  direct  a  proper  attention  to  the  subject. 

To  recapitulate :  I  suggest  that  most  of  the  cases  of  so-called 
idiopathic  or  obscure  trismus  will  be  found  to  depend  on  conditions 
associated  with  the  dental  arch. 

That  to  insure  permanent  relief,  the  treatment  must  include  the 
primary  lesion. 

That  such  primary  lesions  as  are  described  in  the  chapter  on 
"Anomalies"  are  always  distinguishable. 

That  where  it  is  desirable  to  extract  an  offending  wisdom  tooth, 
and  such  extraction  seems  too  difficult  to  attempt,  the  extraction  of 
the  tooth  immediately  anterior  to  it  will  not  unfrequently  be  found 
to  meet  the  indications. 

That  the  immobility  of  the  jaw,  where  acute  inflammatory  action 
exists,  is  to  be  treated  on  general  antiphlogistic  or  phlogistic  princi- 


THE   TEETH  AND    THEIR   DISEASES.  157 

pies,  according  as  it  seems  probable  or  improbable  that  the  inflam- 
mation may  be  resolved. 

That  when  the  acute  action  has  passed,  adhesions  are  to  be 
broken  up  by  mechanical  force  carefully  applied. 

That  meehanico-dental  lesions  are  not  to  be  overlooked,  but  to  be 
searched  for,  and  discovered  secundum  artem. 

Trismus,  it  also  must  be  very  evident,  not  unfrequently  exists 
as  a  result  of  various  traumatic  conditions.  Thus,  anchylosis  has 
been  known  to  result  in  an  articulation,  too  long  denied  motion, 
where  the  jaw  has  been  unduly  kept  fixed  in  fracture.  The  ordinary 
false  anchylosis  is  frequently  associated  with  such  fractures,  a  pa- 
tient being  sometimes  months  in  recovering  the  normal  motions  of 
the  parts.  Trismus  from  cicatricial  bands,  resulting  from  deep  burns, 
is  perhaps  the  most  intractable  form  of  the  condition.  Ulcerations, 
the  result  either  of  ptyalism  or  the  cancroid  affections,  have  some- 
times resulted  in  a  closure  of  the  jaw  entirely  beyond  remedy.  Exos- 
tosis is  occasionally  a  source  of  trismus,  the  articular  condyle  being 
rendered  incapable  of  free  motion. 

To  describe  any  particular  treatment  applicable  to  the  various 
causes  would  be  to  consider  such  causes  in  detail.  This,  it  will  be 
found,  has  been  done  in  various  parts  of  this  work,  as  special  cases 
have  presented  themselves ;  such  conditions  will  be  seen  to  demand 
and  employ  the  ingenuity  and  learning  of  the  surgeon.  In  this 
connection,  as  an  example  of  such  an  application  of  skill  to  the 
overcoming  of  difficulties,  I  may  present  the  somewhat  celebrated 
case  of  Dr.  S.  P.  Hullihen,  of  Virginia.  I  think  it  would  be  difficult 
to  find  a  better  study : 

"  Miss  Mary  S.,  aged  twenty,  daughter  of  the  Hon.  William  S.,  of 
Ohio,  came  to  Wheeling,  in  the  spring  of  1848,  to  obtain  relief  from 
the  effects  of  a  very  severe  burn,  which  she  had  received  fifteen  years 
before.  The  burn  was  principally  confined  to  the  neck  and  lower 
part  of  the  face,  and  its  cicatrix  produced  a  deformity  of  the  most 
dreadful  character.  Her  head  was  drawn  downward  and  forward, 
the  chin  was  confined  within  an  inch  of  the  sternum,  the  under  lip 
was  so  pulled  down  that  the  mucous  membrane  of  the  left  side  came 
far  below  the  chin,  the  under  jaw  was  bowed  slightly  downward, 
and  elongated,  particularly  its  upper  portion,  which  made  it  project 
about  one  inch  and  three-eighths  beyond  the  upper  jaw.  In  front 
there  was  scarcely  any  appearance  of  either  chin  or  neck.  She  was 
unable  to  turn  her  head  to  either  side,  the  cheeks  and  upper  lip  were 
dragged  considerably  downward ;  she  could  not  close  her  eyelids ; 


158  ORAL  DISEASES  AND  SURGERY. 

she  could  not  close  her  jaws  but  for  an  instant,  and  then  only  by 
bowin"-  her  head  forward.  She  could  not  retain  her  saliva  for  a 
single  instant ;  and,  as  might  be  expected,  her  articulation  was  very 
indistinct. 

"  She  had  been  taken  to  the  City  of  New  York,  some  years  before, 
for  the  purpose  of  being  relieved  from  this  deformity,  and  was  placed 
under  the  care  of  two  of  the  most  distinguished  surgeons  in  that 
city,  who  performed  an  operation  by  dissecting  up  the  cicatrix  on 
the  neck,  then  raising  the  head  and  sliding  up  the  cicatrix  from  its 
original  position,  leaving  a  raw  surface  below  to  heal  up  by  granu- 
lation. I  need  scarcely  add  that  the  operation  was  entirely  unsuc- 
cessful. 

"After  a  careful  observation  of  the  case,  it  became  evident  that 
such  a  complicated  deformity  could  be  best  remedied  by  performing 
three  separate  operations:  one  upon  the  jaw,  another  upon  the 
neck,  and  a  third  upon  the  under  lip. 

"  To  remove  the  projection  of  the  under  jaw  seemed  to  require 
the  first  attention.  Unless  that  could  be  done  the  other  operations, 
however  successful,  would  add  but  little,  if  any,  to  the  personal  ap- 
pearance of  the  patient.  This  lengthening  of  the  jaw  had  taken 
place  entirely  between  the  cuspidatus  and  first  bicuspid  tooth  of  the 
right  side,  and  between  the  first  and  second  bicuspids  of  the  left.  By 
the  elongation,  the  teeth  just  described  were  separated  on  both  sides 
about  three-fourths  of  an  inch. 

"  To  saw  out  the  upper  edge  of  these  elongated  portions  of  the 
jaw,  and  then  to  divide  that  part  of  the  jaw  in  front  of  the  spaces 
thus  made,  by  sawing  it  through  in  a  horizontal  manner,  so  as  to 
permit  the  upper  and  detached  portion  to  be  set  back  in  its  original 
position,  appeared  to  be  the  only  possible  way  of  remedying  the 
deformity.  This  plan  I  therefore  adopted,  and  performed  the  opera- 
tion on  the  12th  day  of  June,  in  the  manner  now  to  be  described. 

"  The  operation  was  commenced  by  sawing  out,  in  a  V-shape,  the 
elongated  portions,  together  with  the  first  bicuspid  on  the  left  side, 
each  section  extending  about  three-fourths  ©f  the  way  through  the 
jaw.  I  then  introduced  a  bistoury  at  the  lower  point  of  the  space 
from  which  the  section  was  removed  on  the  right  side,  and  pushed 
it  through  the  soft  parts  close  to  and  in  front  of  the  jaw,  until  it 
came  out  at  the  lower  point  of  the  space  on  the  left  side.  The 
bistoury  was  then  withdrawn,  and  a  slender  saw  introduced  in  the 
same  place,  and  the  upper  three-fourths  of  the  jaw,  containing  the  six 
front  teeth,  was  sawed  off  on  a  horizontal  line,  ending  at  the  bottom 


THE   TEETH  AND    THEIR   DISEASES.  159 

of  the  spaces  before  named,  the  detached  portion  being  still  connected, 
on  the  outer  and  inner  sides,  to  the  jaw  below,  by  the  soft  parts. 

"After  having  with  the  bone  nippers  removed  from  the  detached 
portion  the  corners  which  were  created  by  the  horizontal  and  per- 
pendicular cuts  of  the  saw,  it  was  set  back,  so  that  the  edges  from 
which  the  Y-shaped  sections  were  removed  came  together. 

"  Thus  it  will  be  perceived  that  this  portion  of  jaw  and  teeth, 
which  before  projected  and  inclined  outward,  now  stood  back  and 
inclined  inward,  and  in  its  proper  and  original  place. 

"  In  this  position  the  jaw  was  secured  by  passing  ligatures 
around  the  cuspidati  in  the  detached  portion  and  the  now  adjoining 
bicuspids  in  the  sound  portion ;  then  taking  an  impression  of  the 
jaw  in  very  soft  wax,  a  cast  was  procured,  and  a  silver  plate  struck 
up  and  fitted  over  the  teeth  and  gum,  in  such  a  manner  as  to 
maintain  the  parts  in  that  same  relation,  beyond  the  possibility 
of  movement. 

"  The  patient  declared  that  the  operation  gave  her  little  or  no 
pain.  There  was  a  little  swelling  about  the  chin  during  the  first 
three  days  after  the  operation,  but  not  the  slightest  uneasiness.  In 
this  way  the  case  progressed ;  the  gum  healed  in  a  few  days,  the 
jaw  united  strongly,  and  in  the  time  bones  usually  unite,  and  the 
wearing  of  the  plate  was  discontinued  within  six  weeks  after  the 
operation  was  performed. 

"  The  deformity  of  the  jaw  being  now  removed,  the  next  thing  to 
be  done  was  to  relieve  the  confined  condition  of  the  head,  and  the 
distortion  of  the  face  and  neck  resulting  therefrom.  This  I  de- 
termined to  accomplish,  if  possible,  after  the  manner  of  Professor 
Miitter  in  similar  cases,  and  I  accordingly  performed  the  operation 
on  the  31st  day  of  July,  assisted  by  Dr.  Wissell. 

"  I  began  by  dividing  the  skin  immediately  in  front  of  the  neck, 
about  half  an  inch  above  the  sternum,  and  then  carried  the  incision 
back  about  three  inches  on  each  side.  I  then  commenced  a  careful 
division  of  the  strictures,  which  were  s©  thickened  in  front  as  to  ex- 
tend to  the  trachea,  and  on  the  sides  as  not  only  to  involve  the 
platysma  myeides,  but  a  portion  of  the  sterno-cleido-mastoid  muscle 
also.  After  dividing  everything  that  interfered  with  the  raising  of 
the  head  and  the  closing  of  the  mouth,  as  far  as  the  incision  was 
now  made,  it  became  evident  that,  to  give  free  motion  to  the  head, 
the  incision  on  the  neck  must  be  extended  back  through  the  remain- 
ing cicatrix,  which  was  at  least  two  inches  wide  on  one  side,  and 
about  an  inch  and  a  half  on  the  other. 


160  ORAL  DISEASES  AND  SURGERY. 

"  This  was  accordingly  done,  the  whole  presenting  a  wound  up- 
wards of  nine  inches  in  length  and  nearly  five  in  width.  A  thin 
piece  of  leather  was  now  cut  in  shape  of  the  wound,  but  somewhat 
larger,  and  placing  it  upon  the  shoulder  and  arm,  immediately  over 
the  deltoid  muscle,  a  flap  nearly  ten  inches  in  length  and  five  in 
breadth,  having  an  attachment  or  neck  two  inches  wide,  was  marked 
out,  and  then  dissected  up  as  thick  as  the  parts  below  would  permit. 
This  flap  was  now  brought  around  and  secured  in  the  wound  on  the 
neck  by  the  twisted  suture,  the  sutures  being  placed  about  an  inch 
and  a  half  apart.  Between  each  of  these  sutures,  one,  two,  and 
sometimes  three  small  stitches  were  inserted,  depending  entirely 
upon  the  number  necessary  to  bring  the  edges  neatly  together. 
These  stitches  were  of  fine  thread,  had  a  very  superficial  hold,  pro- 
duced little  or  no  irritation,  and  served  to  keep  the  parts  in  better 
apposition  than  any  other  means  I  could  have  devised.  The  wound 
of  the  shoulder  was  next  drawn  together  about  one-half  of  its  entire 
extent;  the  remainder  was  covered  with  lint.  @ne  long,  narrow 
strip  of  adhesive  plaster  applied  around  the  neck  to  support  the  flap, 
and  over  this  a  cravat  tied  in  the  usual  way,  constituted  all  the 
dressing  deemed  advisable  at  this  time. 

"  The  patient  bore  this  tedious  and  very  painful  operation  with 
great  fortitude,  and  uttered  scarcely  a  murmur.  She  was  somewhat 
exhausted,  but  not  from  the  loss  of  blood.  There  was  no  vessel 
divided  of  sufficient  importance  to  require  a  ligature. 

"August  1st.  During  the  fore  part  of  last  night  the  patient  was 
somewhat  distressed,  was  very  unmanageable,  would  talk  inces- 
santly, and  occasionally  sat  up  in  bed.  An  anodyne  was  adminis- 
tered at  twelve  o'clock,  after  which  she  rested  much  better  and  slept 
some.  Complains  of  sickness  of  the  stomach  this  morning;  has 
vomited  three  or  four  times ;  flap  very  pale ;  pulse  rather  weak. 
Directed  to  refrain  from  all  kinds  of  drinks. 

"  2d.  Complains  only  of  pain  in  the  shoulder ;  was  much  dis- 
tressed the  latter  part  of  last  night,  on  account  of  a  retention  of 
urine.  The  catheter  was  employed,  and  about  three  pints  of  urine 
drawn  ofi",  after  which  she  rested  well.  Pulse  somewhat  excited ; 
flap  better  color. 

"  3d.  The  patient  rested  well  last  night ;  the  use  of  the  catheter 
still  necessary.  All  eff"orts  to  keep  the  patient  from  talking  and 
moving  unavailing ;  color  of  the  flap  rather  pale,  save  at  the  ex- 
treme point  and  about  two  inches  along  the  lower  edge,  which  is 
assuming  rather  a  dark-blue  color.    Pulse  about  the  same  as  yester- 


THE   TEETH  AND    THEIR  DISEASES.  161 

day;  removed  a  pin  from  near  the  point  of  the  flap,  and  enveloped 
the  neck  in  cotton  batting.  Patient  complains  of  hunger ;  chicken 
broth  ordered. 

"4th.  Patient  rested  well ;  the  use  of  the  catheter  yet  necessary; 
complains  of  slight  headache ;  the  color  of  the  flap  nearly  natural, 
and  even  the  point  is  assuming  a  healthy  hue,  and  appears  to  be 
uniting ;  pulse  almost  natural. 

"  5th.  Urinates  without  difiiculty ;  bowels  moved  by  injections ; 
patient  entirely  free  from  pain ;  pulse  natural. 

"6th.  Dressing  removed  ;  the  flap  is  uniting  by  the  first  intention 
along  both  sides,  throughout  its  entire  extent ;  the  greater  part  of 
the  pins  and  stitches  removed. 

"  7th.  The  remainder  of  the  pins  and  stitches  removed ;  patient 
perfectly  comfortable  and  cheerful. 

"  10th.  Sat  up  all  day  by  the  window. 

"  16th.  Walked  out  to  take  an  airing. 

"  During  the  whole  progress  of  the  cure,  there  was  not  the  slight- 
est swelling  or  undue  inflammation  in  the  flap  or  about  the  neck. 
The  patient  was  slightly  hysterical  for  the  first  few  days,  but  never 
complained  of  anything  but  pain  in  the  shoulder,  a  slight  headache 
of  a  few  hours'  duration,  and  the  uneasiness  occasioned  by  the  re- 
tention of  urine.  The  wound  on  the  shoulder  granulated  rapidly 
and  skinned  over  in  about  six  weeks  after  the  operation.  It  was 
curious  to  observe  that  upon  touching  the  flap  after  it  had  healed  in 
the  neck,  the  patient  would  always  refer  the  sensation  to  the  shoulder 
or  arm  from  which  the  flap  was  taken. 

"  The  confinement  of  the  head  and  the  distortion  of  the  face  occa- 
sioned by  the  strictures  being  now  removed,  the  next  step  was  to 
relieve,  as  far  as  possible,  the  very  great  deformity  of  the  under  lip. 

"  The  under  lip,  from  being  dragged  down  and  greatly  stretched 
by  the  former  projection  of  the  under  jaw,  was  rendered  greatly  too 
large,  so  that  it  pouted  out  an  inch  or  more  farther  than  the  upper 
lip.  This,  together  with  a  turning  out  of  the  mucous  membrane  on 
the  left  side,  which  extended  nearly  down  to  the  lower  edge  of  the 
chin,  making  the  lip  too  short  on  that  side,  was  the  nature  of  the 
deformity  yet  to  be  relieved. 

"  To  remove  this  unseemly  appearance  of  the  lip,  the  inverted 
portion  was  cut  out  in  a  Y-shape,  extending  down  to  the  flap  in  the 
neck,  and  sufficiently  large  to  reduce  the  lip  to  its  proper  size.  The 
edges  were  then  brought  together,  and  secured  after  the  manner  of 
a  single  hare-lip.     The  wound  healed  in  the  most  beautiful  manner, 

11 


162  ORAL  DISEASES  AND  SURGERY. 

aud  the  appearance  of  the  lip  was  greatly  improved ;  but  there  yet 
remained  a  deep  depression  or  notch  in  the  edge,  sufficiently  large 
to  keep  exposed  the  tops  of  two  or  three  teeth,  besides  preventing 
the  coming  together  of  the  lips  on  that  side. 

"  I  now  determined  to  raise,  if  possible,  this  depressed  portion  of 
the  lip,  aud  for  this  purpose  I  passed  a  bistoury  through  the  lip, 
about  two  lines  from  the  free  edge,  first  on  one  side  of  the  depres- 
sion, and  then  on  the  other,  and  then  carried  the  incisions  down- 
ward to  meet  at  a  point  on  the  lower  edge  of  the  chin. 

"  The  depressed  portion  of  lip  now  lying  between  the  two  inci- 
sions was  next  dissected  loose  from  the  jaw,  and  then  raised  to  a 
level  with  the  remainder  of  the  lip,  and  there  retained  by  pins,  after 
the  manner  of  dressing  a  double  hare-lip,  the  line  of  union  forming  a 
letter  \. 

"  This  operation  was  as  successful  as  the  others,  and  the  original 
deformity  being  now  removed,  the  young  lady,  though  still  bearing 
evidences  of  the  burn,  has  the  free  use  of  her  head,  eyelids,  jaws, 
and  lips,  and  may  mingle  in  society  without  particular  note  or 
remark." 

This  case,  although  not  one,  strictly  speaking,  for  the  cure  of 
trismus,  is  yet,  however,  so  analogous  to  certain  traumatic  con- 
ditions of  this  kind,  that  no  special  case  with  which  I  am  acquainted 
contains  as  much  of  just  that  particular  order  and  kind  of  operative 
proceeding  required  in  this  direction  of  surgery,  and  necessary  to 
be  understood  and  appreciated  by  the  surgeon. 


CHAPTER    IX. 

THE   DISEASES   OF   THE   TEETH. 
CARIES. 

Caries  of  the  teeth  is  a  chemico-vital  action,  and  most  markedly 
a  trouble  of  hereditary  transmission  and  predisposition.  So  true  is 
this,  that  it  may  be  prognosed  that  the  ofifspring  of  parents  afflicted 
in  this  way  will  be  in  like  afflicted,  and  that  on  the  other  band  the 
children  of  parents  possessing  good  teeth  will  be  in  like  favored.  So 
marked,  indeed,  is  this  analogy  in  the  teeth  of  parent  and  child,  that 
in  most  instances  it  extends  to  the  very  shapes  and  arrangement 
of  the  organs,  thus  deformity  insuring  deformity,  and  regularity, 
regularity.     One  parent  alone  may  thus  influence  for  good  or  evil. 

Caries  of  the  teeth,  allowing  for  differences  in  structure,  and  con- 
sequently in  impressibility,  is  to  be  viewed  as  most  analogous  to 
caries  of  the  bone  proper,  and,  consequently,  is  most  scientifically 
treated  as  caries  in  bone  is  treated — in  other  words,  dental  caries  is 
more  a  vital  or  constitutional,  than  a  local  or  chemical  trouble,  or 
it  is  chemico-vital,  as  syphilitic  caries  of  bone  is  chemico-vital,  or 
as  scrofulous  caries  is  chemico-vital.  In  syphilitic,  scrofulous, 
mercurial,  or  other  commonly  recognized  dyscrasiac  caries,  the  prac- 
titioner feels  that  three  distinct  requirements  are  to  be  met :  1.  The 
natural  forces  are  to  be  increased.  2.  The  specific  condition  is  to 
be  conquered.  3.  The  local  indications,  or  the  caries,  are  to  receive 
local  attention.  In  common  dyscrasiac  caries  of  the  teeth,  or  in 
caries  not  of  peculiar  or  special  hereditary  transmission,  these  prin- 
ciples of  treatment  are  to  apply,  and  if  justly  appreciated,  and 
the  constitutional  condition  discovered  and  understood,  the  prac- 
titioner must  find  that  he  can  cure  the  one  caries  as  he  cures  the 
other. 

In  the  caries  of  peculiar  hereditary  transmission,  that  is,  of  that 
special  something  which  exhibits  itself  alone  in  the  direction  of 
the  teeth  without  any  evident  constitutional  dyscrasia,  we  are  to 
treat  and  hope,  just  as  we  treat  and  hope  in  the  phthisis  of  trans- 

(163) 


164  ORAL  DISEASES  AND  SURGERY. 

mission.  It  is  to  be  a  treatment  on  general  principles,  and  is  com- 
pelled, too  often,  to  be  experimental.  It  can  certainly  only  be  dif- 
ferential. Unfortunately,  in  the  one  case,  as  in  the  other,  medication 
seems  to  stand  us  to  no  very  satisfactory  end, — the  lung  will  break 
down,  and  the  tooth  will  break  down, — it  is  only  a  matter  of  time, 
or,  might  I  better  say,  a  matter  of  an  inability  on  our  part  to  appre- 
ciate cause  and  treatment. 

In  connection  with  an  inability  on  the  part  of  the  teeth — as  the 
vital  force  is  concerned — to  resist  deteriorating  acute  tendencies,  we 
have,  not  unfrequently,  to  contend  with  certain  direct  physical  im- 
perfections, which,  like  the  wooden  horse  of  Troy,  gives  ingress  to 
the  enemy,  which  otherwise  might  have  been  resisted.  Examina- 
tion of  the  teeth,  particularly  the  pre-  and  posterior  molars,  ex- 
hibits, quite  too  frequently,  irregularities  in  the  protecting  covering 
of  enamel,  breaks  in  the  continuity,  as  it  were,  particularly  in  the 
various  sulci.  In  these  depressions  lodge  and  decompose  the  various 
ingesta  of  diet,  acting,  of  course,  as  irritants,  and  producing,  as  I 
believe,  just  the  same  character  of  eflfect  as  would  be  produced  in  any 
bone ;  that  is,  inflammation,  yet  modified,  of  course,  by  differences 
which  exist  between  the  tooth  bone  and  ordinary  bone ;  it  is,  however, 
inflammation  in  the  one  case,  and  inflammation  in  the  other ;  the 
matter  of  acids  and  alkalies  have  little  to  do  with  the  matter,  except 
as  they  are  agents  of  irritation.  If  proof  is  needed  of  these  asser- 
tions, it  seems  fully  enough  found  in  the  resistive  ability  of  common 
healthy  dentine,  from  which  the  enamel  has  been  so  cut  as  to  make 
the  surface  a  self-cleansing  one.  Witness  the  filed  teeth  of  the  South 
Sea  Islander ;  or,  to  come  directly  home,  witness  the  everyday  re- 
sults of  ordinary  dental  operations.  One  practitioner  files  the  teeth 
so  that  the  surfaces  shall  always  present  inclined  planes,  another 
wedges  teeth  apart,  files  off  the  enamel,  in  the  process  of  getting 
ready  a  carious  cavity  for  filling,  and  the  operation  completed,  re- 
moves his  wedge,  and  allows  the  exposed  faces  of  the  dentine  to 
fall  together;  the  one,  a  self-cleansing  surface,  remains  healthy, 
the  second,  non-cleansing,  soon  again  takes  on  ulcerative  action  or 
decay. 

A  tooth,  then,  may,  in  its  vital  relations,  be  just  strong  enough 
to  resist  external  forces  brought  to  bear  upon  it,  if  in  its  construc- 
tion there  is  no  mechanical  imperfection.  It  may  again,  even  with 
such  imperfections,  be  able  to  resist  injurious  impressions,  as  is 
often  enough  witnessed. 

Integrity  of  the  teeth  we  shall  assume  to  depend  on  two  con- 


DISEASES  OF   THE   TEETH.  165 

ditions:  inherent  vital  resistive  power,  and  the  absence  of  irritating 
influences.  The  vitality  of  a  tooth  can  be  elevated  as  the  vitality 
of  a  lung  is  increased  Irritating  influences,  both  internal  and  ex- 
ternal, can  be  met  and  combated,  in  the  one  case  as  in  the  other. 

The  study  of  the  vitality  of  a  tooth,  and  the  study  of  its  adverse 
influences  is  the  study  of  vitality  anywhere.  The  treatment  is,  of 
course,  constitutional,  and  is  to  be  appreciated  by  the  practitioner  if 
he  would  be  successful  in  his  efforts. 

In  viewing,  from  a  systemic  stand-point,  the  composition  of  the 
teeth,  we  have  primarily  to  remark,  that  the  component  parts  are 
formed  from  and  preserved  by  that  chemico-vital  relationship  ex- 
isting between  blood  and  parts  to  be  nourished.  We  recognize, 
and  know,  that  in  that  fluid  which  we  denominate  blood  resides 
the  element  of  nutrition,  and  that  as  this  material  is  well  or  illy 
adapted  to  meet  the  requirements  of  the  different  tissues,  so  are 
these  tissues  found  to  be  in  varying  states  of  health.  We  infer 
that  blood,  rich  in  the  elements  of  tooth-structure,  is  capable  of 
yielding  good  teeth,  provided  the  process  of  similation  resides  to  a 
proper  extent  in  the  part  to  be  built  up  and  nourished,  so  that  the 
study  of  caries,  from  the  constitutional  stand-point,  consists  in  looking 
at  the  condition  of  the  blood  and  the  amount  of  vital  force  residing 
in  the  teeth  themselves. 

A  tooth  in  its  composition  is  made  up  of  cementum,  dentine, 
enamel,  and  pulp  substance.  Excluding  the  pulp  substance,  we 
find,  with  some  variation,  the  relative  proportions  of  organic  and 
inorganic  matter  to  be  as  follows : 

Cementum.    Dentine.        Enamel. 

Organic  matter 29-27        28-70  3-59 

Inorganic  matter 70-73         71-30        96  41 

The  character  of  this  inorganic  material  we  find,  by  a  more  com- 
plete analysis,  to  be  as  follows :  phosphate  of  lime,  fluate  of  lime, 
carbonate  of  lime,  phosphate  of  magnesia,  salts. 

The  composition  of  healthy  blood  yields  the  following  analysis: 

Water 780-15 

Fibrin 2-10 

Albumen 6809 

Coloring  matter 133-00 

Cystallizable  fat 2-43 

Fluid  fat 1-31 

Extractive  matter 1-79 

Albumen,  in  combination  with  soda 1-26 


166  ORAL  DISEASES  AND  SURGERY. 

Chloride  of  sodium  and  potassium  ;  carbonates,  phosphates, 

and  sulphates  of  potash  and  soda 8-37 

Carbonates  of  lime  and  magnesia ;  phosjjhates  of  lime,  mag- 
nesia, and  iron  ;  peroxide  of  iron 4-60 

1000  00 

In  a  healthy  and  normal  condition  of  the  human  system  we  find 
always  the  existence  of  a  relationship  between  the  requirements 
and  material  of  supply  which  should,  and  which  does,  afford  proper 
tissue;  where  then  such  conditions  exist,  the  teeth  are  perfectly 
formed,  and,  as  constitutional  relations  are  concerned,  are  healthily 
preserved. 

In  the  study  of  the  pathological  conditions  of  these  organs,  we 
are  to  discover,  if  possible,  wherein  the  harmony  of  demand  and 
supply  has  been  interfered  with,  and  that  we  may  look  at  the  sub- 
ject from  the  most  comprehensive  stand-point,  we  begin  with  that 
period  of  dental  evolution  in  which  the  primary  impressions  are  pro- 
duced. In  this  connection,  I  know  of  no  one  who  has  given  a  more 
exhaustive  attention  to  the  subject  than  the  late  James  Paul,  M.D.; 
and  I  recognize  that  I  could  not  afford  the  subject  better  expression 
than  by  embodying  the  substance  of  a  paper  read  by  that  gentleman 
before  the  Medical  Society  of  Mercer,  N.  J.  The  views  cannot  re- 
ceive a  too  careful  study. 

"  The  subject,"  says  Dr.  Paul,  "  is,  not  only  in  a  physiological 
point  of  view,  one  of  interest,  but  in  its  application  to  the  preserva- 
tion of  health — the  tendency  to  improve  the  general  condition  and 
physical  constitution  of  the  human  family  inhabiting  this  great  con- 
tinent—  a  continent  abounding,  as  it  does,  in  all  the  productions 
which  a  bountiful  Creator  in  his  beneficence  bestows  on  man — 
cannot  be  otherwise  than  of  great  and  paramount  importance. 

"At  a  period  somewhat  now  remote,  the  celebrated  naturalist, 
Buffon,  alluding  to  the  animals  of  this  continent,  advanced  the  fol- 
lowing opinions : 

"  1st.  That  the  animals  common  both  to  the  Old  and  New  Worlds 
are  smaller  in  the  latter. 

"  2d.  That  those  belonging  to  the  New  are  on  a  smaller  scale. 

"  3d.  That  those  which  have  been  domesticated  in  both,  have  de- 
generated in  America. 

"  4th.  That,  on  the  whole,  it  exhibits  fewer  species. 

"  These  opinions,  Mr.  Jefferson,  in  his  '  Notes  on  Virginia,'  under- 
took, and  it  is  generally  considered  successfully,  to  controvert ;  yet, 


DISEASES  OF  THE   TEETH.  167 

however  repugnant  to  the  general  idea  the  opinion  as  to  the  tend- 
ency of  those  animals  which  have  been  domesticated  in  America 
from  other  countries  to  degenerate,  it  is  an  undeniable  and  much  to 
be  regretted  fact,  that  the  human  family,  and  more  particularly  the 
female  portion  of  that  family,  have  declined  in  the  vigor  and  strength 
of  their  physical  constitution. 

"  I  wish  not  to  be  misunderstood:  I  say  it  is  a  melancholy  fact, 
too  well  known  to  the  observant  physiologist,  that  increase  of 
strength  and  development  of  frame  have  not  been  attained  by  the 
intermarrying  of  members  of  the  human  family  of  different  nations 
on  this  continent;  but  the  reverse  is  too  observable;  the  physical 
frame  of  the  female  sex  has  degenerated — calling  loudly  for  the  aid 
of  science  to  arrest  an  evil  of  so  much  magnitude. 

"  Let  us  for  a  moment  contemplate  the  female  form,  as  seen  on 
this  broad  continent.  In  no  country  in  the  world  are  children  more 
fair  and  beautiful;  and  as  the  young  girl  grows  up  to  womanhood, 
we  see  in  her  a  full  realization  of  that  being  forming  in  the  hands  of 
Divinity,  portrayed  by  the  poet,  as  seen  by  Adam  in  his  dream  : 

"  '  Under  his  forming  hands,  a  creature  grew 
Manlike,  but  different  sex ;  so  lovely  fair 
That  what  seemed  fair  in  all  the  world,  seemed  now 
Mean,  or  in  her  summed  up,  in  her  contained, 
And  in  her  looks.' 

"  We  see  this  young  and  lovely  being — the  forehead  well  devel- 
oped— the  countenance,  rather  elongated,  relieved  of  the  harsher 
outline  of  some  of  the  European  nations — with  fragile  form,  and 
small,  yet  well-developed  bust,  flitting  for  a  few  short  years  among 
us,  and  then — yes,  then  there  comes  a  change.  Ere  five-and-twenty 
summers  pass,  this  flower  begins  to  fade — the  rounded  form  shrinks 
— the  bloom  of  health  decays  ;  and  if  she  escapes  the  fell  destroying 
angel's  deathlike  grasp,  a  wreck  of  former  self  remains. 

"  Why  should  this  be  so  ?  The  robust  of  other  countries  come 
to  this  continent — they  live  in  comfort — their  food  is  excellent  in 
quality — their  progeny  is  like  themselves — but  even  now,  in  the  very 
first  generation,  does  the  degenerating  process  make  itself  manifest 
— the  teeth  begin  to  decay ;  and  girls,  while  yet  children,  have  to 
visit  the  dentist  to  have  them  cleansed,  scraped,  and  plugged. 

"Now  this  brings  us  at  once  to  the  head  and  front  of  our  subject; 
and  if  we  can  point  out  the  first  cause  of  this  decay  of  what  should 
be  as  strong  as  adamant,  it  may  be  the  means  of  helping  us  in  our 
investigation.     That  there  is  something  radically  wrong  in  our  sys- 


168  ORAL  DISEASES  AND  SURGERY. 

tern  of  rearing  the  young,  to  which  this  misfortune  is  in  a  great 
measure  owing,  I  am  free  to  confess  is  my  firm  opinion.  I  would 
indeed  it  were  in  my  power,  in  pointing  out  the  evil,  to  be  as  success- 
ful in  detailing  the  cause,  that  we  may  apply  the  remedy.  Still, 
although  perhaps  unable  to  accomplish  all  I  wish,  my  observations 
may  not  be  without  their  weight,  and  induce  others,  more  observant, 
more  scientific,  and  more  competent  to  the  task,  to  follow  up  an  in- 
vestigation so  fraught  with  advantage  to  our  fellow-beings. 

"  It  is  certainly  to  be  deplored  that  the  females  of  this  continent, 
descendants  of  European  parents,  should  be  so  much  afflicted  with 
caries  of  the  teeth — the  decay  of  parts  formed  of  substances  which 
enter  into  the  composition  of  some  of  our  hardest  minerals — marble, 
bone-earth,  and  fluor-spar;  and  this  decay  unfortunately  occurs  in 
early  life — in  girls  yet  at  school ;  and  many  a  young  woman,  ere 
she  has  attained  a  marriageable  age,  has  had  to  replace  the  natm'al 
with  the  unnatural,  though  more  enduring  enamel  of  the  artist's 
formation.  This  ought  not  to  be:  God  made  all  mankind  alike;  in 
no  portion  of  the  earth  are  nations  found  who  lose  their  hands,  or 
feet,  or  tongue,  or  eyes ;  and  there  can  be  no  cause  why  the  inhabit- 
ants of  this  land  should  lose  their  teeth.  It  is  not  so  in  the  olden 
countries  from  whence  the  progenitors  of  the  present  race  have 
come;  nor  is  it  so  in  the  West  India  islands,  which  may  almost  be 
considered  as  part  of  this  great  continent.  So  excellent  is  the  struc- 
ture of  the  teeth  of  savage  nations,  that  some  tribes  in  Africa,  I 
think  the  Mocoes  and  Mundingoes,  file  all  the  front  teeth,  so  that 
they  shall  be  separated  and  form  sharp  points,  the  better  to  tear  the 
uncooked  animal  food. 

"  One  cause  of  this  affliction  is,  in  the  mind  of  many,  attributed 
to  the  great  and  sudden  changes  of  temperature  experienced  on  this 
continent — the  thermometer  rising  and  falling  20,  30,  and  even  40 
degrees  in  twelve  hours.  But  if  attributable  to  these  sudden 
changes,  we  know  that  sudden  expansion  by  means  of  heat,  or  sud- 
den contraction  by  means  of  cold,  causes  the  particles  of  which 
bodies  are  composed  to  tear  themselves  asunder ;  consequently  to 
crack,  break,  and  fall  in  pieces.  But  this  is  not  the  case  with  the 
teeth  of  our  females;  a  caries  or  decay  commences  most  generally  in 
the  side  of  the  tooth,  extending  to  the  enamel,  which  is  sometimes 
involved  in  the  destruction ;  at  other  times,  it  is  left  a  crust  or  shell 
to  snap  and  break  off  in  small  pieces,  when  unable  to  resist  the 
pressure  of  whatever  may  be  placed  against  it;  besides,  the  teeth 
are  for  the  most  part  sheltered  from  these  sudden  changes,  and  kept 


DISEASES  OF   THE    TEETH.  169 

at  a  temperature  nearly  amounting  to  blood  heat  at  all  seasons.  I 
do  not  think  we  can  place  the  general  destruction  of  the  teeth,  and 
consequent  affliction  of  the  females  of  America,  to  this  cause.  I 
fear  we  must  rather  look  for  it  to  constitutional  weakness,  and  this 
constitutional  weakness  to  a  deficiency  of  the  inorganic  or  earthy 
constituents  being  taken  into  the  system,  more  particularly  at  an 
early  period  of  life.* 

"  If  I  am  correct  in  this  opinion,  and  reason,  philosophy,  and  a 
thorough  examination  of  physiological  facts  in  both  the  animal  and 
vegetable  economy,  tend  far  to  bear  out  these  views,  then  if  we 
would  try  and  correct  this  lamentable  state  of  things,  let  us  com- 
mence at  the  very  beginning,  and  make  ourselves  acquainted  by 
examining  the  structure  and  composition  of  the  teeth,  and  then  we 
shall  be  more  able  to  understand  what  is  required  to  aid  nature  in 
their  formation  and  consequent  preservation. 

"  First,  then,  let  us  make  ourselves  acquainted  with  the  structure 
and  composition  of  the  teeth.  The  teeth  are  nearly  allied  to  bone 
in  structure  ;  both  having  earthy  deposits,  intermixed  with  fibers  and 
cells  of  gelatin,  which,  by  consolidation,  gives  form  and  strength — 
in  the  case  of  bone,  to  bear  the  weight  of  the  various  parts,  and 
afford  protection  to  the  different  organs  of  the  body  ;  and  in  the  case 
of  teeth,  to  cut  and  grind  the  food  required  for  the  formation,  sup- 
port, and  reparation  of  its  various  parts. 

"Now,  teeth  are  composed  of  three  different  substances,  ^and 
these  three  are  disposed  according  to  the  purposes  required  of  them ; 
they  are  cementum  or  crusta  petrosa,  dentine  (known  as  ivory  in  the 
tusk  of  the  elephant),  and  enamel.  The  cementum  or  crusta  pe- 
trosa corresponds  in  all  especial  particulars  with  bone ;  possessing 
its  characteristic  lacunae  or  small  cavities,  and  being  traversed  by 
vascular  medullary  canals,  whenever  it  occurs  of  suflScient  thickness ; 
it  is  the  first  covering  of  the  young  teeth,  and  may  be  said  to  invest 
the  fang  of  the  tooth  which  enters  the  alveolar  process  of  the  jaw. 
The  dentine  or  ivory  consists  of  a  firmer  substance,  in  which  inor- 
ganic or  mineral  matter  predominates,  though  to  a  less  degree  than 
in  enamel.  It  is  traversed  by  a  vast  number  of  very  fine  cylindri- 
cal, branching,  wavy  tubuli,  which  commence  at  the  pulpy  cavity, 
and  radiate  toward  the  surface.     The  diameter  of  these  tubuli,  at 


"  Experiments  have  demonstrated  that  teeth  may  be  changed  instantly 
from  iced  to  boiling  water  without  cracking  the  enamel.  Injury  to  the  teeth 
from  thermal  changes  would  arise  rather  from  irritation  inflicted  on  the  pulp. 


170  ORAL  DISEASES  AND  SURGERY. 

their  largest  part,  average  about  1-10, 000th  of  an  inch;  their 
smallest  are  iinineasurably  fine  ;  so  much  so,  that  they  cannot  pos- 
sibly receive  blood,  but  it  is  surmised  that,  like  the  canaliculi  of  bone, 
they  imbibe  fluid  from  the  vascular  lining  of  the  pulp  cavity,  which 
aids  in  the  nutrition  of  the  tooth.  The  enamel  is  composed  of  solid 
prisms  of  fibers,  about  the  l-5600th  of  an  inch  in  diameter,  ar- 
ranged side  by  side,  and  closely  adherent  to  each  other  ;  their  length 
corresponds  with  the  thickness  of  the  layer  which  they  form ;  and 
the  two  surfaces  of  this  layer  present  the  ends  of  the  prism,  which 
are  usually  more  or  less  hexagonal.  In  the  perfect  state,  the  enamel 
contains  but  an  extremely  minute  quanity  of  animal  matter.  In  the 
center  of  the  tooth  is  the  soft  pulpy  cavity,  which  affords  a  bed  for 
the  blood-vessels  and  nerves  which  supply  it  with  life  and  sen- 
sibility. 

"  I  shall  not  enter  more  minutely  into  the  structure  of  the  teeth, 
but  may  briefly  state,  that  like  all  other  structures  of  the  animal 
body,  the  component  parts  are  derived  and  deposited  from  the 
blood,  by  that  mysterious  and  incomprehensible  power  that  selects 
and  deposits  the  necessary  constituents  in  the  formation  of  the 
several  portions,  according  to  the  use  required. 

"  Now,  in  the  composition  of  the  teeth,  we  have  first  the  division 
into  organic  and  inorganic  or  earthy  matter;  and  we  find  that  the 
several  substances  which  enter  into  the  structure  of  the  teeth,  differ 
chiefly  as  to  the  earthy  matter  contained  in  each. 

"  Chemical  analysis  of  the  incisors,  or  front  teeth  of  man,  shows 
that  they  contain  in  one  hundred  parts  of  each,  as  follows : 

Cementum.     Dentine.         Enamel. 

Organic  matter 29-27         28  70  3-59 

Earthy  matter 70-73         71-30        96-41 


100-         100-  100- 

"  These  proportions  will  occasionally  differ;  in  some  individuals 
the  organic  constituents  having  less  than  here  stated,  amounting  in 
the  dentine  only  to  21.  The  analysis  of  bone,  however,  gives  a 
much  larger  proportion,  viz.: 

Organic  matter 32-56 

Earthy  matter 67-44 


100- 


"  Let  us   now  take  a  more   complete  analysis,   showing  what 
earthy  constituents  enter  into  their  composition.     Analysis  of  the 


DISEASES   OF   THE    TEETH.  171 

molar  or  grinding  teeth  of  man,  and  of  the  bones  of  the  arm  and  leg 
of  a  man  of  forty,  show  the  following  proportions  : 

Inorganic  matter : 

Phosphate  of  lime,  with  traces  of  fluate     Dentine.        Enamel.  Bone. 

of  lime 66-72  89-82  54-61 

Carbonate  of  lime 3-36  4-37  9-41 

Phosphate  of  magnesia 1-08  1-34  1-07 

Salts,  etc -83  -88  2-35 

Organic  matter 28-01  3-59  32-56 

100-  100-  100- 

"  Thus  we  see  the  very  great  proportion  of  certain  earths  that 
enter  into  the  structure  of  the  teeth  and  the  bone  of  man,  the  chief 
substance  being  the  phosphate  of  lime,  familiarly  known  as  bone- 
earth.  We  find,  too,  that  whereas  in  ordinary  bone  the  phosphate 
of  lime  constitutes  only  54  parts  in  100,  in  the  enamel  of  the  teeth 
it  is  nearly  90  parts  in  100 — while  the  carbonate  of  lime  in  bone 
amounts  to  9-41,  in  the  enamel  of  teeth  it  is  only  4-3Y;  the  enamel 
being  literally  almost  a  mineral  in  substance,  having  only  3-59  parts 
of  animal  matter  in  100. 

"Thus  the  teeth  to  be  strong  and  durable,  require  a  large  quantity 
of  earthy  ingredients,  particularly  lime,  to  enter  into  their  compo- 
sition. Let  us  inquire  whence  it  is  derived  ;  and  for  this  we  must 
examine  the  blood. 

"  To  allow  of  such  deposits  from  the  blood,  it  is  first  necessary 
that  they  should  be  held  in  solution  in  that  fluid.  The  blood  circu- 
lates to  every  portion  of  the  body  by  the  action  of  the  heart,  which 
forces  a  certain  quantity,  say  2  oz.  at  every  contraction,  into  the 
aorta  or  great  canal  leading  from  the  left  ventricle — the  aorta 
divides  and  subdivides  into  innumerable  branches,  which  are  made 
to  ramify  to  every  part  of  the  body,  until  the  extreme  branches  end 
in  capillary  tubes  or  vessels,  the  caliber  of  which  is  so  small  as  not 
to  allow  the  red  globules  or  corpuscles  of  the  blood  to  enter  them, 
but  which  allows  the  serous  portion  to  traverse  every  part  of  the 
organized  structure,  holding  in  solution  all  those  constituents  neces- 
sary and  requisite  for  the  formation  and  reparation  of  its  several 
parts. 

"  In  the  serous  portion  of  the  blood,  then,  we  find  contained  the 
constituents  required  for  the  composition  of  bone  and  teeth — analysis 
of  1000  parts  of  healthy  human  blood  giving,  according  to  M.  Lecanu, 
the  following  proportions : 


172  ORAL  DISEASES  AND  SURGERY. 

"Water 780-15  785-58 

Fibrin.. 2-10  3-57 

Albumen 6509  69'41 

Coloring  matter 13300  119-63 

Crystallizable  fat 2-43  4-30 

Fluid  fat 1-31  2-27 

Extractive  matter,  uncertain 1-79  192 

Albumen  in  combination  with  soda 1-26  2  01 

Chlorides  of  sodium  and  potassium  ;  carbonates, 

phosphates,  and  sulphates  of  potash  and  soda.  8-37  7-30 
Carbonates  of  lime  and  magnesia  ;  phosphates 

of  lime,  magnesia,  andiron;  peroxide  of  iron.  2-10  1-42 

Loss 2-40  2-50 


1000-  1000- 

"We  see  by  this  table,  if  we  subtract  or  take  away  the  proportion 
of  water  amounting  to  780  parts,  and  the  coloring  matter  amounting 
to  138,  we  shall  leave  scarcely  90  parts  of  organic  and  earthy  ma- 
terial, the  salts  and  earths  forming  upwards  of  a  10th — the  salts 
being  in  proportion  to  the  earths  as  4  to  1. 

"  Having  then  shown  the  constituent  portions  of  the  bones  and 
teeth  to  be  in  the  blood,  the  next  consideration  is,  whence  are  they 
derived  ? 

"  Before  entering  on  this  subject  further,  let  us  for  a  moment  take 
a  broader  and  more  comprehensive  view  of  what  must  be  most  in- 
teresting to  mothers,  and  of  great  consequence  to  the  well-being  of 
the  infant  generation,  in  a  short  time,  in  a  very  few  years,  to  become 
in  their  turn  the  mothers  and  fathers  of  another  generation. 

"  The  question  then  presents  itself,  what  is  the  nourishment  or 
food  best  adapted  and  necessary  to  the  wants  of  an  infant,  that  the 
foundation  may  be  laid  for  a  strong  frame  and  vigorous  constitution  ? 
For  here,  we  must  recollect,  is  the  starting-point  in  by  far  the  ma- 
jority of  instances.  We  know  that  in  some  cases  disease  is  hered- 
itary— that  the  offspring  unfortunately  inherits  from  the  parents 
constitutional  defects ;  but  we  also  know  that  more  misery,  suffer- 
ing, and  constitutional  derangement  are  entailed  on  children  by 
want  of  care  and  improper  food  in  the  first  years  of  life,  by  which 
their  hopes  of  health  are  blasted,  and  they  are  doomed  to  struggle 
through  a  weary  life,  to  be  hurried  at  last  into  a  premature  grave. 

"  Now,  that  the  frame — that  is,  the  bones,  muscles,  and  other 
portions  of  the  infant — may  be  fully  developed,  it  is  necessary  that 
it  should  be  supplied  with  nourishment,  containing  all  the  con- 
stituents required  for  this  important  undertaking.    And  this  nourish- 


DISEASES  OF  THE   TEETH.  I73 

ment,  by  the  all-wise  ordering  of  Providence,  is  contained  in  the 
milk  secreted  from  the  mother's  bosom. 

"  The  infant  is  entirely  dependent  on  the  nourishment  derived 
from  its  mother,  and  nature  has  wisely  ordained  that  the  secretion 
from  the  mother  is  its  very  best  food ;  for  we  find  in  the  composi- 
tion of  milk — that  is,  healthy  milk,  derived  from  healthy  blood — 
all  those  ingredients  we  have  hitherto  traced  as  requisite  in  the 
formation  of  the  bones  and  teeth,  and  not  only  these,  but  every  con- 
stituent required  for  the  life  and  growth  of  the  individual ;  milk 
containing  the  albuminous,  saccharine,  oleaginous,  saline,  and  earthy 
compounds  requisite  and  necessary  for  the  health,  strength,  and  de- 
velopment of  the  infant  child. 

"An  analysis  of  cow's  milk  gives  the  following  proportions  of  the 
various  constituents ;  that  of  human  milk  is  not  so  elaborate,  but 
contains  the  average  of  observations  taken  at  fourteen  different  times 
from  the  same  individual,  by  Simon. 

Cow's  Milk  bt  M.  Haidlen. 

Water 87300 

Butter 3000 

Casein 4820 

Milk  sugar 43-90 

Phosphate  of  lime 2-31 

Phosphate  of  magnesia -42 

Phosphate  of  iron -07 

Chloride  of  potassium 1*44 

Chloride  of  sodium -24 

Soda  in  connection  with  casein -42 

1000- 
Woman's  Milk  by  Simon. 

Water 883-6 

Butter 25-3 

Casein 34-3 

Milk  sugar  and  extractive  matter 48-2 

Pixed  salts 2-3 

1000- 

Maximum  of  Minimum  of 

1-i  observations.  14  observations. 

Butter 540  8-0 

Casein 45-2  10-6 

Sugar  and  extractive  matter 62-4  392 

Salts 2-7  1-6 


174  ORAL  DISEASES  AND  SURGERY. 

"  Now,  although  these  amounts  will  no  doubt  vary,  under  every 
variety  of  circumstances,  according  to  the  health,  exercise,  jjassio7is, 
and /oo(/  of  the  mother,  yet  they  show  that  healthy  milk  contains 
all  the  requisites  for  the  nourishment  of  the  infant;  but  then  it  must 
be  healthy  milk,  secreted  from  healthy  blood,  and  that  blood  must 
derive  these  ingredients  from  the  food  consumed. 

"  Cow's  milk  differs  from  that  of  woman  in  the  proportions  of  i 
some  of  the  constituents,  it  abounds  more  in  butter,  but  particularly  , 
in  casein,  or  cheese ;  and  on  the  other  hand,  human  milk  abounds  ' 
more  in  tbe  saccharine  principle,  or  sugar  of  milk.  Now  this  points  ; 
out  a  circumstance  from  which  great  benefit  may  be  derived.  It  is  ; 
of  very  frequent  occurrence  that  infants  are  deprived  of  the  natural  i 
nourishment  of  the  mother,  and  diverse  opinions  are  given  relative  ' 
to  the  food  of  infants  by  persons  who  really  know  very  little  about 
the  matter;  one  recommends  a  milk  diet,  another  that  the  infant 
must  be  fed  on  starch  and  sugar. 

"  Xow,  to  enable  the  infant  to  receive  a  nourishment  in  every  re- 
spect similar  to  the  mother,  the  knowledge  of  the  various  propor- 
tions which  we  obtain  by  chemical  analysis  enables  us  to  rectify 
and  produce  milk  very  analogous  to  human  milk  from  that  of  the 
cow,  by  diluting  it  with  water  in  the  proportion  of  about  half  as 
much  again  ;  that  is,  to  a  pint  of  milk  should  be  added  half  a  pint  of 
water  that  has  been  boiled,  which  will  reduce  the  cheese  principle  to 
the  proper  proportion ;  add  a  small  portion  of  cream  to  restore  the 
proportion  of  butter,  and  then  add  sugar  until  the  whole  is  dis- 
tinctly sweetened,  and  we  have  a  compound  in  every  respect  similar 
to  the  milk  from  the  human  breast. 

"  To  understand  the  subject  of  nutrition,  let  us  remember  that 
food  should,  or  must  embody  two  great  principles :  one  to  nourish, 
the  other  to  give  heat  to  the  body.  And  food,  when  consumed,  is 
applied  to  one  or  the  other  of  these  purposes.  Now,  in  the  process 
of  digestion,  the  constituents  of  the  food  are  separated,  and  arranged 
in  three  classes: 

"  1st.  All  that  portion  derived  from  animal  food,  eggs,  the  curd 
of  milk,  the  gluten  or  adhesive  portion  of  wheat  and  other  grain, 
and  whatever  in  animal  or  vegetable  food  can  be  rendered  into  albu- 
men — of  which  the  best  example  that  can  be  offered  in  illustration  is 
the  lohite  of  egg,  which  is  in  reality  nearly  pure  albumen — and  the 
principle  is  therefore  called  albuminous. 

"  2d.  All  that  portion  of  the  food  derived  from  vegetables,  starch, 
sugar,  etc.  that  can  be  converted  into  suga7-  in  the  process  of  diges- 
tion.    This  principle  is,  therefore,  called  saccharine. 


DISEASES   OF  THE    TEETH.  175 

"3(1.  All  the  fat,  butter,  oil,  etc.  which,  when  deprived  of  the 
other  substances,  is  left  in  the  state  of  oil,  and  thei'efore  called  ole- 
aginous. 

"  Now,  of  these  three  the  albuminous  is  the  nutrient,  and  the 
saccharine  and  oleaginous  the  calorifacient,  or  heat-giving;  and 
chemicial  analysis  shows  that  they  vary  in  composition. 

ALBUMEX.  OLEAGINOUS. 

Eggs.  Wheat.        Mutton  fat. 

Carbon 55000  5501         78996 

Hydrogen 7073  723        11-700 

Nitrogen 15-920  15-92 

Oxygen          ^  9-304 

Sulphur          [ 22-007  21-84 

Phosphorus  J  

SACCHARIDE. 

Starch,              Sugar  Sugar       Cane 

arrow-root,  from  starch,  of  milk,    sugar. 

Carbon 44-40          37-29  40-00   42-301 

Hydrogen 6-18            6-84  6-61      6-384 

oiygen 49-42          55-87  52-93   51-315 

"  It  will  be  observed  that  the  albuminous  or  nutrient  differs  from 
the  saccharine  and  oleaginous,  in  containing  nitrogen,  and  sulphur 
and  phosphorus,  with  carbon,  hydrogen,  and  oxygen,  while  the  latter 
contains  only  carbon,  hydrogen,  and  oxygen — nitrogen  being  re- 
quired in  those  compounds  which  give  strength  and  formation  to 
the  frame. 

"  Now  the  albuminous  or  nutritive,  being  that  portion  which 
affords  nourishment  to  the  body,  contains  those  constituents  re- 
quired in  the  first  place  for  the  formation  and  giving  strength  to  the 
different  portions  of  the  body,  and  when  fully  developed,  of  repair- 
ing the  general  waste  continually  going  on  in  the  system,  whether 
from  the  usual  wear  and  tear,  fractured  bones,  or  the  ravages  of 
disease.  And  the  saccharine  and  oleaginous — the  calorifacient  or 
heat-making — to  keep  up  a  continual  supply  of  fuel,  as  it  were,  that 
the  body  may  be  kept  of  a  regular  and  proper  temperature ;  for  all 
are  no  doubt  aware  that  there  is  a  continual  supply  of  carbon,  or, 
in  more  simple  language,  of  charcoal,  required  to  keep  up  the  natural 
temperature  of  the  body;  and  what  is  not  required  for  immediate 
use  is  stored  away  in  the  form  of  fat,  to  be  called  into  action  as 
occasion  requires. 

"  We  have  seen  in  the  analysis  of  milk  that  that  fluid  contains 


176  ORAL  DISEASES  AND  SURGERY. 

butter,  cheese,  and  sugar ;  consequently  we  can  understand  how  an 
infant  can  thrive  so  well  upon  it, — the  cheese  or  casein*  of  the 
milk,  containing  the  nitrogenized  or  nutrient  principle,  which,  to- 
gether with  the  earths  and  salts  contained  in  the  milk,  goes  to  form 
the  bones,  muscles,  and  the  different  tissues  of  the  body,— the  sugar, 
which  we  have  seen  by  the  analysis,  contains  a  large  quantity  of 
carbon  in  its  composition,  going  to  keep  up  the  temperature  of  the 
infant,  while  the  butter,  in  the  nature  of  fat,  is  stored  away  in  a 
healthy  infant,  filling  up  every  vacant  interstice,  causing  a  round- 
ness and  plumpness,  the  pride  and  joy  of  the  happy  parent. 

"  Now  let  us  mark  the  difference  of  the  babe  that  has  been  denied 
a  milk  diet,  and  is  doomed  by  ignorance  to  be  fed  on  starch  and 
sugar.  We  will  recollect  that  these  two  substances  were  composed 
of  carbon,  hydrogen,  and  oxygen  only.  By  a  process  of  digestion 
which  I  need  not  here  enter  into,  such  food  is  converted  into  sugar, 
the  carbon  of  which  becomes  the  fuel  by  which  the  temperature  of 
the  body  is  kept  up— there  being  no  principle  in  the  food  to  give 
albumen,  there  is  nothing  taken  into  the  stomach  upon  Avhich  the 
gastric  fluid  can  expend  its  solvent  powers ;  the  infant  is,  therefore, 
much  troubled  with  acid  eructations,  and  the  stomach  becomes  weak 
and  irritable.  The  want  of  the  nutritive  constituent  of  the  food, 
and  the  earths  and  salts,  etc.  necessary  and  essential  for  the  forma- 
tion of  the  bones  and  teeth,  show  a  lamentable  deficiency  in  the 
child's  development;  and  there  being  no  fatty  matter  to  be  laid  up, 
the  body  is  emaciated,  the  countenance  is  ghastly,  the  flesh  and  in- 
teguments hang  soft  and  flabby  over  the  bones;  no  absolute  disease 
can  be  detected ;  the  child  is  ravenous  and  hungry,  and  the  unfortu- 
nate babe  descends  to  the  tomb  a  specter  and  an  object  of  the  most 
pitiful  description.  This  is  no  fancy  sketch,  but  one  too  often  met 
with  in  the  ordinary  walks  of  professional  life.  And  why  is  it  so? 
Simply  because  the  composition  of  the  human  frame,  the  component 
parts  of  our  food  requisite  to  produce  that  frame,  and  the  process  of 
digestion  and  nutrition,  are  so  little  understood. 


*                                                                        Analysis  of  Albuminous  substances  found 

casein  from  in  whey  after  coagulation 

fresh  milk.  with  an  acid. 

Carbon 5-1-825  54-96 

Hydrogen 71,53  715 

Nitrogen 15-628  15-89 

Oxygen  ■»  21-73 


Sulphur  J  22-394  0-36 


DISEASES   OF  THE   TEETH.  177 

"We  now  advance  from  infancy  to  childhood — and  this  is  a  period 
when  the  greatest  attention  is  required  in  supplj'ing  nutriment  to 
aid  nature  in  the  great  work  of  developing  the  body.  The  child  is 
now  deprived  of  the  maternal  secretion,  and  dependent  on  food  pre- 
pared for  its  use  by  the  hand  of  man, — perhaps  living  in  a  city,  and 
deprived  of  pure  and  wholesome  milk  from  the  cow.  And  we  know 
there  is  a  vast  disproportion  in  the  quality  of  milk  when  the  cow  is 
country  fed  on  the  natural  productions  of  the  farm,  and  when  city 
fed  on  slops  and  grain,  the  refuse  of  the  brewery. 

"  It  is  at  this  age  that  the  great  proportion  of  bony  substance  is 
deposited  ;  those  of  the  extremities  are  lengthened,  become  more 
compact  and  stronger,  and  the  substance  of  the  teeth  is  deposited  in 
the  cells  of  gelatinous  tissue.  How  necessary  is  it,  then,  that  this 
subject  should  receive  the  utmost  attention  of  parents.  It  has 
hitherto  been  too  much  the  custom  to  leave  all  this,  as  belonging 
entirely  to  nature,  as  a  thing  we  had  nothing  to  do  with.  We  have 
been  too  much  in  the  habit  of  considering  that  nature  furnished  her 
own  materials,  and  man  had  nothing  to  do  with  her  operation.  The 
potter  cannot  fashion  the  bowl  without  the  clay,  neither  can  bone  be 
formed  without  earth :  nature  must  be  supplied  with  the  material, 
which,  although  offered  in  the  most  incongruous  forms,  she  has  the 
power  of  decomposing,  selecting  from,  and  supplying  for  the  various 
purposes  required  :  one  portion,  as  we  have  already  stated,  to  act  as 
fuel  in  keeping  up  the  temperature ;  another  portion  she  selects  to  add 
to  the  flesh,  the  muscle,  skin,  and  different  tissues ;  and  the  earths 
which  are  held  in  solution,  she  carries  away  by  vessels  adapted  for 
that  purpose,  and  deposits  them  atom  by  atom,  until  they  are  so 
compressed,  so  strongly  compacted  together,  as  to  become  what  we 
call  solid  bone, — and  all  this  so  wonderfully  wrought  that,  as  we 
have  seen,  small  tubes  are  left  in  the  hard,  stony  formations  both 
of  the  bones  and  of  the  teeth,  that  nourishment  may  be  supplied 
them,  holding  in  solution  the  material  of  which  they  are  composed, 
that  the  natural  waste  and  decay  may  be  replaced,  and  injuries 
repaired. 

"  It  is  to  this  nutrition,  and  of  the  earthy  matter  of  which  the 
bones  and  teeth  are  composed,  a  deficiency  of  which  is  attended 
with  results  so  deplorable,  that  I  particularly  wish  to  call  attention. 

*'  To  what  can  we  attribute  the  calamity  which  too  often  befalls 
the  young?  I  allude  to  distorted  spines,  where  the  bones  compos- 
ing the  spine,  instead  of  forming  a  column,  allowing  the  body  to  be 
erect  and  dignified,  are  zigzag  in  their  course,  causing  one  shoulder 

12 


178  ORAL  DISEASES  AND  SURGERY. 

to  bulge  out,  and  the  opposite  side  to  bend  or  double  upon  itself. 
This  deformity  has  been  long  understood  to  arise  from  a  deficiency 
of  lime  in  the  composition  of  the  bones  of  the  vertebrae,  allowing 
them  to  fall,  press  upon,  and  injure  each  other,  destroying  the 
beauty  of  the  fabric,  and  the  health  and  comfort  of  the  individual. 

"  Now  let  us  take  a  glance  at  the  inhabitants  of  two  countries, 
natives  of  which  are  no  strangers  on  this  continent.  I  take  them  as 
examples,  because  the  food  of  the  common  people  of  those  countries 
is  well  known  to  be  of  the  most  common  kind.  I  allude  to  natives 
of  Scotland  and  Ireland — the  principal  food  of  one  being  oatmeal, 
and  of  the  other  potatoes.  We  have  heard  a  great  deal  of  the  fam- 
ishing poor  of  those  countries,  and  particularly  of  the  latter, — of  the 
misery  and  wretchedness  seen  in  every  hovel ;  and  there  cannot  be 
a  doubt  that  famine  walked  through  the  land,  when  the  blight  and 
rot  despoiled  them  of  their  potato  crop,  on  which,  for  so  long  a 
period,  they  depended  as  the  great  article  of  food.  Now,  allow- 
ing all  this — allowing,  in  the  best  seasons,  the  chief  article  of  sub- 
sistence has  been  potatoes  for  breakfast,  dinner,  and  supper ;  glad 
indeed  many  of  them  to  get  a  little  animal  food  once  a  week  to  din- 
ner, or  even  far  more  seldom — I  now  ask,  what  number,  in  the 
thousands  of  emigrants  from  that  country  who  yearly  arrive  at  our 
ports,  are  there  that  show  a  constitution  weak,  fragile,  and  wanting 
in  physical  strength  ?  Many,  no  doubt,  arrive,  worn  down  by  dis- 
ease and  suffering,  and  in  the  last  stage  of  debility ;  but  let  them 
recover  from  that  state,  and  the  robust  frame  and  healthy  constitu- 
tion will  be  again  developed ;  the  bones  are  strong,  the  teeth  unde- 
cayed,  and  the  muscular  energy  only  wanting  opportunity  to  dis- 
play itself; — in  fact,  when  we  wish  to  denote  strength  in  woman, 
we  use  the  familiar  phrase,  '  strong  as  an  Irish  woman,'  and  all 
this  from  being  reared  on  potatoes*     But  then,  if  we  examine  the 

*  According  to  a  memorial  presented  to  the  French  minister,  on  the  pro- 
portions of  nutriment  of  the  means  of  living,  by  Dr.  Glaser,  we  find  potatoes 
taking  no  mean  rank. 

NrXRITIVE    ELEMENTS. 

100  lbs.  wheat  bread  contains  30  lbs. 

"  flesh  "  21  lbs. 

"  fresh  beans  "  80  lbs.  ^ 

"  peas  "  83  lbs.  i  casein  and  starch. 

"  lentils  "  94  lbs.  J 

"  potatoes  "  2.5  lbs.,  albumen,  starch,  and  sugar. 

"  carrots  •'  14  lbs.  -, 

'•  beets  "  8  lbs   f  ^Ihumen  with  sugar. 


DISEASES   OF   THE    TEETH.  179 

analysis  of  the  potatoes,  we  shall  find  contained  in  100  parts  of  dry- 
potatoes, — 

Carbon 41-1 

Hydrogen 58 

Nitrogen  \ 45.I 

Oxygen .. ) 

Ashes 50 

"  Here  we  see  that  potatoes  not  only  contain  the  nutrient  but  the 
earthy  constituents. 

"  But  we  have  a  stronger  and  more  healthy  race  yet,  from  Scotland 
and  the  north  of  Ireland,  who  are  generally  descendants  of  the 
Scotch,  and  continue,  in  a  great  measure,  the  same  means  in  rearing 
the  young.  Now,  a  principal,  I  will  not  say  the  principal  food  of 
the  youth  of  Scotland,  high  and  low,  rich  and  poor,  except  in  the 
larger  cities,  among  those  who  class  themselves  as  more  refined  and 
more  civilized,  but  who  number  few  in  proportion,  consists,  for  break- 
fast, at  least,  of  oatmeal — that  is,  porridge  and  milk ;  and  milk,  po- 
tatoes, and  wheaten,  oaten,  or  pease  bread,  or  bannocks,  at  other 
times  of  the  day.  Animal  food  among  the  poor  is  a  rarity ;  a  meat 
dinner  on  Sunday  only  being  common.  Even  among  the  youth  of 
the  better  class,  butcher's  meat,  or  animal  food,  is  by  no  means  a 
principal  article  of  subsistence.  And  I  would  particularly  remark 
that  Scotch  oatmeal  (the  oatmeal  generally  used  throughout  Scot- 
land) is  coarse,  and  contains  much  of  the  bran  which  invests  the 
oat — containing,  as  it  does,  a  large  proportion  of  the  earthy  constit- 
uents required  for  the  production  of  bone.  Analysis  of  100  parts  of 
dried  oats  gives, — 

Carbon 50-7 

Hydrogen 64 

Oxygen 36-7 

Nitrogen 22 

Ashes 4-6 

"I  may  here  casually  remark,  that  the  advantage  to  be  derived 
from  this  wholesome  food  has  not  escaped  the  observation  of  her 
Majesty,  Queen  Victoria,  who  appears  in  the  multiplicity  of  her 
public  duties  not  to  lose  sight  of  the  equally  sacred  duties  of  a 
mother — and  we  hear  of  her  son,  the  heir  to  the  crown  of  Great 
Britain,  being  as  fond  of  his  oatmeal  porridge  as  the  meanest  peas- 
ant child  in  Scotland. 

"  I  rather  doubt  if  parents  generally  have  given  to  this  subject  the 


180  ORAL  DISEASES  AND  SURGERY. 

attention  to  which  it  is  entitled.  I  trust,  however,  that  those  who 
have  followed  me  thus  far,  may  be  impressed  with  its  importance.  We 
cannot  shut  our  eyes  to  the  complaint  which  so  generally  prevails,  of 
decayed  teeth and  a  moment's  reflection  will  call  to  mind  the  num- 
ber of  the  young  and  beautiful  who  are  prematurely  hurried  to  the 
tomb,  ere  yet  the  bud  has  expanded  into  the  full-developed  flower. 
Nay,  comparing  the  two  countries,  the  statistics  of  life  and  death 
communicate  to  us  also  the  important  fact,  that  while  the  greatest 
mortality  shows  itself  in  England  in  infancy  and  childhood,  on  this 
side  the  Atlantic  it  is  found  at  a  more  mature  age. 

"  Neither  has  the  tendency  of  the  physical  organization  of  woman 
on  this  continent  to  degenerate,  escaped  the  observation  of  one  of 
our  greatest  medical  philosophers  in  this  country,*  who  regai'ds  this 
retrogression  as  a  national  calamity,  and  impresses  upon  his  students 
the  importance  of  the  subject,  and  the  propriety  of  their  attention  in 
attempting  to  arrest  it ;  and  he  particularly  specifies  the  great  object 
to  be  gained  in  the  use  of  bran-bread  made  from  unbolted  flour.  On 
this  head  I  shall  have  more  to  say  hereafter. 

"With  these  observations,  let  us  now  direct  our  attention  to  what 
can  be  offered  in  remedy  of  this  evil. 

"  We  have  already  stated  that  in  no  country  in  the  world  are 
children  more  beautiful  or  more  lovely  —  healthy  in  complexion, 
quick,  smart,  and  intelligent — active,  sprightly,  and  playful  in  their 
disposition.  Now,  in  the  period  from  infancy  until  the  child 
becomes  mature — let  us,  at  all  events,  say  until  thirteen  or  four- 
teen years,  and  even  to  a  more  advanced  age — there  is  a  con- 
tinued growth — a  continual  deposition  of  organic  and  inorganic  or 
earthy  particles,  which  are  required  for  the  formation  of  bone,  teeth, 
flesh,  and  every  part  of  the  human  body.  1  have  shown  that  the 
essential  ingredients  for  these  several  formations  are  all  found  in  the 
milk  of  the  mother;  consequently,  as  long  as  the  infant  is  deriving 
nourishment  from  the  mother,  she  ought  to  partake  of  good  whole- 
some, nourishing  food — that  the  blood,  deriving  these  principles 
from  the  food,  may  be  able  to  supply  them  in  turn  to  the  milk  from 
which  it  is  secreted.  So  long,  then,  as  the  child  is  thus  nourished, 
so  long  is  it  safe,  and  the  rudiment  or  foundation  of  a  robust  frame 
is  laid.  And  if  we  are  to  expect,  in  future  life,  the  stalwart  frame 
of  man,  or  the  enduring,  firmly-knit,  compact,  and  healthy  physical 
constitution  in  woman,  the  organic  and  inorganic  or  earthy  com- 


*  Dr.  Jackson,  of  Philadelphia. 


DISEASES   OF  THE    TEETH.  181 

pounds  of  which  that  frame  is  composed  must  not  be  denied — nature 
must  be  supplied,  or  nature  will  fail 

"  It  is  not  for  me  to  dictate  to  any  parent  what  shall  be  the  food 
of  his  child — it  is  enough  that  I  point  out  for  their  information  what 
may  be  required  to  give  what  in  common  language  is  called  '  bone 
and  sinew,'  to  their  offspring.  It  is  necessary  then  that  the  food  of 
children  shall  contain : 

"1st.  Aliment  having  the  calorifacient  or  heat-sustaining  prin- 
ciple. And  this  is  contained  in  quite  sufficient  quantity  in  the  usual 
food — in  milk,  wheaten-bread,  potatoes,  arrow-root,  Indian  corn  (as 
mush,  hominy,  or  corn-breadj,  in  most  vegetable  matter,  and  in 
sugar. 

"2d.  Aliment  containing. the  nutrient  principle.  And  this  is  con- 
tained in  animal  food — the  lean  of  beast,  bird,  and  fish — in  milk, 
eggs,  wheat,  rye,  potatoes,  beans,  etc. 

"And  3d.  Aliment  containing  the  inorganic  or  earthy  constitu- 
ents— on  which  depends  strength  of  frame,  and  from  which  are 
formed  the  bones  and  teeth  of  the  individual.  And  these  are  con- 
tained in  milk,  eggs,  animal  food,  and  particularly  in  wheat,  rye, 
oats,  potatoes,  etc.* 


*  On  this  subject,  I  extract  the  following  from  Carpenter's  Physiology,  p. 
488:  "  These  substances  are  contained,  more  or  less  abundantly,  in  most  arti- 
cles generally  used  as  food;  and  where  they  are  deficient,  the  animal  suifers 
in  consequence,  if  they  are  not  supplied  in  any  other  way.  Thus,  common 
salt  exists,  in  no  inconsiderable  quantity,  in  the  flesh  and  fluids  of  animals, 
in  milk  and  in  eggs;  it  is  not  so  abundant,  however,  in  plants;  and  the 
deficiency  is  usually  supplied  to  herbivorous  animals  by  some  other  means. 
Phosphorus  exists  also  in  the  yolk  and  white  of  the  egg,  and  in  milk ;  and  it 
abounds  not  only  in  many  animal  substances  used  as  food,  but  also  (in  the 
state  of  phosphate  of  lime  or  bone-earth)  in  the  seeds  of  many  plants,  espe- 
cially the  grasses.  In  smaller  quantities,  it  is  found  in  the  ashes  of  almost 
every  plant.  Sulphur  is  derived  alike  from  vegetable  and  animal  substances. 
It  exists  in  flesh,  eggs,  and  milk  ;  also  in  the  azotized  compounds  of  plants  ; 
and  (in  the  form  of  sulphate  of  lime)  in  most  of  the  river  and  spring-water 
that  we  drink.  Iroit  is  found  in  the  yolk  of  egg  and  in  milk,  as  well  as  in 
animal  flesh ;  it  also  exists  in  small  quantities  in  most  vegetable  substances 
used  as  food  by  man — such  as  potatoes,  cabbage,  peas,  cucumbers,  mustard, 
etc.  Lime  is  one  of  the  most  universally  difl"used  of  all  mineral  bodies  ;  for 
there  are  few  animal  or  vegetable  substances  in  which  it  does  not  exist.  It 
is  most  commonly  taken  in,  among  the  higher  animals,  combined  with  phos- 
phoric acid :  in  this  state  it  exists  largely  in  the  seeds  of  most  grasses,  and 
especially  in  wheat-flour.  If  it  were  not  for  their  deficiency  of  lime,  some  of 
the  leguminous  seeds  (peas)  would  be  more  nutritious  than  wheaten-flour; 


182  ORAL  DISEASES  AND  SURGERY. 

"Of  the  inorganic  constituents  contained  in  wheat  (and  the  same 
may  be  said  of  the  other  cereal  grains)  I  have  already  alluded  to 
the  benefit  to  be  derived  from  using  bread  made  of  unbolted  flour. 
On  this  subject  allow  me  to  refer  to  the  difference  of  flour  having 
much  of  the  bran  remaining,  and  superfine  flour,  or  that  in  general 
use  throughout  this  country,  and  on  which  Prof  Johnston  has  made 
the  followiug  curious  but  practical  observations.  Examining  wheat 
and  flour,  as  to  the  amount  of  the  nutrient  or  muscular  matter,  the 
fat- forming  principle,  and  the  bone  and  saline  material,  contained  in 
grain  in  diff"erent  states,  he  found — 

Muscular  matter.  Fat  principle.  Bone  and  salt. 

In  1000  lbs.  of  whole  grain 156  lbs.         25  lbs.  170  lbs. 

"          fine  flour 130    "          20    "  60" 

"         "          bran 60    "  700  " 

"  Taking  the  three  substances  together,  according  to  Prof.  John- 
ston, of  a  thousand  pounds,  the  three  substances  contain  of  the  in- 
gredients mentioned, — 

Whole  grain.  Fine  flour. 

Of  muscular  matter 156  lbs.  130  lbs. 

Of  bone  material 170    "  60    " 

Offat 28    "  20    " 

354  lbs.  210  lbs. 

"Accordingly,  the  whole  grain  is  one-half  more  nutritious  than 
fine  flour.*  It  also  shows  the  very  great  proportion  of  bone  mate- 
rial— that  is,  earthy  constituents — contained  in  the  bran ;  no  less 
than  TOO  out  of  a  thousand  parts,  or  a  little  more  than  tico-thirds  of 
the  whole.  Now,  by  reference  to  the  same  work,  we  find,  in  a  com- 
munication from  a  Mr.  Bentz,  the  difl'erence  in  weight  of  a  barrel  of 
flour  without  the  bran,  and  when  only  the  outer  coating  of  the  wheat 
is  taken  of.  He  says,  '  The  weight  of  the  bran  or  outer  coating 
would,  therefore,  in  the  common  superfine  flour,  constitute  the  offal, 
weighing  only  5j  lbs.  to  the  barrel  of  flour,  while  the  ordinary 
weight  of  offal  is  from  65  to  TO  lbs.  to  each  barrel  of  flour ;  showing 
a  gain  of  from  59|to  65  lbs.  of  wheat  in  every  barrel  of  flour.'  Now 
if  we  estimate  the  earthy  constituents  to  be  two-thirds  of  the  oflfal 
or  bran,  we  must  consider  that  there  is  an  actual  loss  of  these  im- 

the  proportion  of  azotized  matter  they  contain  being  greater.     A  consider- 
able quantity  of  lime  exists,  in  the  state  of  carbonate  and  sulphate,  in  all 
hard  water." 
*  Patent  Office  Report,  1847,  p.  116. 


DISEASES   OF   THE    TEETH.  183 

portant  constituents,  which  might  be  reserved,  in  every  barrel  of 
flour,  of  40  lbs. 

"Again,  if  we  estimate  (according  to  the  average  of  the  consump- 
tion of  flour  to  the  amount  of  population,  as  one  barrel  to  each  indi- 
vidual) that  every  child  shall  consume  aunually  only  half  a  barrel  of 
flour,  then  we  find  that  by  the  use  of  the  superfine  flour,  as  com- 
monly used  in  families,  the  child  is  deprived  yearly  of  twenty  lbs. 
of  those  earthy  substances  which  are  required  to  form  the  bones  and 
the  teeth.  When  we  speak  of  a  child  consuming  half  a  barrel  of 
flour  annually,  it  appears  a  large  quantity  ;  but  when  we  reduce  the 
same  to  a  daily  allowance,  we  find  that  it  is  little  more  than  4  oz.  or 
4^  oz.;  and  every  parent  must  know  that  this  would  be  a  very  small 
amount  to  limit  children.  Yet  we  see  how  large  a  quantity  of  the 
bony  material  would  be  added  if  unbolted  flour  was  used  instead  of 
the  present  superfine  flour.  I  may  here  add,  that  the  oatmeal  used 
in  Scotland,  already  referred  to,  contains  the  bran  or  inorganic  con- 
stituents, while  the  oatmeal  used  in  England  is  deprived  of  it.  Now 
this  is  a  great  loss  of  the  most  valuable  constituents  in  only  one  of 
the  principal  articles  of  the  food  of  children ;  and  if  we  allude  to 
another  article,  which  is  largely  used  on  this  continent, — I  mean 
Indian  corn  (and  I  may  also  add  the  fat  of  meat,  both  of  which, 
children,  if  allowed,  will  partake  of  very  freely), — we  shall  find  that 
both  of  these  abound  more  in  the  calorifacient  or  heat-sustaining 
principle,  and  for  the  deposition  of  fat,  than  the  nutrient,  and  that 
they  are  quite  deficient  of  the  earthy  material  of  lime — that  material 
on  which  so  much  depends  the  proper  structure  of  the  teeth.  An- 
alysis of  Indian  corn  shows  the  following  composition — as  taken 
from  Mr.  Salisbury's  prize  essay — read  at  the  New  York  Agricultu- 
ral Society  for  1849: 

Whole  kernel. 

Starch 50-64 

Sugar  and  extractive 746 

Sugar 1-50 

Piber 6-28 

Matter  separated  from  fiber 0'05 

Albumen 8-64 

Casein 1-70 

Gluten 4-56 

Oil 400 

Dextrine  or  gum 4-84 

Water 10-22 

99-89 


184  ORAL  DISEASES  AND   SURGERY. 

Ash  of  the  kernel  constituting  about  two  per  cent. 

Carbonic  acid a  trace. 

Silicic        "    1'450 

Sulphuric"    0206 

Phosphoric  acid o0-955 

Phosphate  of  iron 4-355 

Lime 0150 

Magnesia lG-530 

Potash 8-286 

Soda 10-908 

Chloride  of  soda 0-249 

Organic  acid 3-400 

97-000 

"  This  is  a  most  elaborate  analysis — far  more  minute  than  any 
analysis  we  have  had  of  any  of  the  articles  of  food — in  fact,  more 
minute  than  satisfactory ;  for  the  analysis  of  the  whole  kernel  does 
not  exhibit  any  amount  of  inorganic  constituent ;  and  when  the 
whole  was  converted  into  ashes,  we  find  that  the  lime  only  amounts 
to  the  one-sixth  of  one  part  in  a  hundred.  Now,  on  inquiry,  I  find, 
on  the  authority  of  a  very  intelligent  miller  of  this  city,  that  in 
grinding  corn,  the  bran  or  thin  skin  of  the  grain  is  detained  in 
forming  it  into  corn-meal ;  consequently,  it  is  deprived  of  even 
that  portion  more  particularly  containing  the  earthy  constituents. 
This  gentleman,  in  conversation,  mentioned  an  important  fact  rela- 
tive to  this  deficiency  of  lime  in  corn.  To  the  best  of  my  recol- 
lection, he  observed,  '  This  stands  to  reason ;  for,  ten  years  ago, 
all  the  lower  part  of  Jersey  grew  excellent  corn,  but  would  not 
grow  wheat ;  but  since  the  introduction  of  lime  as  a  manure  they 
have  raised  considerable  wheat  crops.'  Now  the  fact  is,  it  is  not 
the  habit  or  food  of  this  plant,  even  had  lime  been  in  the  earth ;  and 
magnesia  and  the  saline  manures  are  recommended  to  the  agricul- 
turist as  best  suited  for  its  proper  development. 

"  It  is  generally  looked  upon  as  invidious,  and  one  is  more  likely 
to  incur  odium  than  to  receive  credit  for  saying  one  word  against  a 
food  which  stands  so  high  in  public  estimation,  and  is  so  universally 
used  over  this  continent.  Yet  it  must  not,  for  one  moment,  be  sup- 
posed that  I  condemn  the  use  of  Indian  corn  in  its  various  forms  of 
mush,  hominy,  bread,  or  pudding  as  an  article  of  diet ;  far  from  it. 
But  containing,  as  it  does,  a  large  proportion  of  starch  and  fatty 
matter,  rather  a  small  proportion  of  the  nutrient  principle,  and  quite 
a  deficiency  of  the  inorganic  or  earthy  constituents,  I  consider  it  as 
valuable,  as  a  light  diet,  for   heatrsustaining   purposes  only,   and 


DISEASES   OF   THE    TEETH.  185 

therefore  a  desirable  adjunct  to  other  food,  containing  more  nutri- 
ment and  a  due  proportion  of  the  earthy  constituents. 

"As  an  example  or  illustration  of  the  want  of  the  nutrient  prin- 
ciple in  corn  or  corn-meal,  I  may  here  allude  to  the  effects  I  have 
seen  in  the  West  Indies,  where,  in  a  dearth  of  the  ordinary  provi- 
sions on  which  prisoners  were  fed,  corn-meal  was  substituted;  corn- 
meal  and  salted  herrings,  fish,  etc.  constituting  their  food.  Now  the 
effect  was,  that  all  the  prisoners  lost  their  natural  strength  ;  at  the 
same  time  they  became  fat  and  bloated,  inclining  to  dropsy:  and  this 
was  not  the  effect  of  incarceration  ;  for  the  prisoners  were  engaged 
in  road-making,  trimming  fences,  etc.,  consequently,  in  a  healthy  and 
exhilarating  employment. 

"In  reference  to  our  domesticated  animals,  it  may  be  asked,  Why 
is  corn  so  useful,  as  an  article  of  food,  to  animals  generally — horses, 
hogs,  sheep,  etc.?  I  have  already  shown  that  the  overplus  of  the 
calorifacient  food,  after  what  may  be  required  for  sustaining  the 
temp^ature,  is  stored  away  in  the  form  of  fat.  Now,  if  we  instance 
the  horse,  corn  is  generally,  if  not  always,  given  as  an  adjunct  to  his 
more  usual  food,  hay.  And  we  find  by  analysis  that  grass  or  hay 
contains  not  only  the  nutrient  principle,  but  the  inorganic  constitu- 
ents required  in  the  formation  of  bone,  etc. 

"  One  hundred  parts  of  dry  hay  contain — 

Carbon 45-8 

Hydrogen 5-0 

Oxygen 38-7 

Nitrogen* 1-5 

Ashesf 9-0 

100- 

"  Thus,  the  hay  gives  to  the  animal  strength  in  bone  and  muscle, 
while  the  corn  supplies  additional  heat-sustaining  properties,  and 
lays  by,  in  the  form  of  fat,  the  overplus  as  a  reserve.  The  harder 
the  horse  is  worked,  the  more  corn  he  can  bear ;  the  great  propor- 
tion of  the  carbon  being  carried  off  by  the  lungs,  and  the  hydrogen 
and  oxygen,  as  water,  in  exhalation  and  perspiration.  But  if  the 
same  quantity  is  given  to  a  horse  at  rest,  it  overloads  him  with  fat, 
which,  in  his  case,  accumulates  more  internally,  or  around  the  in- 
ternal organs,  and  will,  in  course  of  time,  induce  disease ;  while  in 

*  Fifteen  pounds  of  such  hay,  containing  oz.  3-095  of  nitrogen, 
f  These  ashes  having  a  good  proportion  of  lime. 


186  ORAL  DISEASES  AND  SURGERY. 

the  pig,  under  similar  circumstances,  the  fat  is  laid  on  externally,  if 
I  may  so  speak,  giving  the  rich  fat  pork  of  our  markets.  And  here 
I  would  again  remark,  that  no  farmer  would  consider  it  necessary 
or  essential  to  give  corn  to  a  young  colt  or  horse,  until  required  to 
work ;  nay,  so  careful  is  nature,  in  appropriating  just  so  much  and 
no  more  of  any  constituent  that  may  be  required,  that  the  food  of 
the  young  horse  should  be  more  nutritious  than  heat-sustaining,, 
and  that  there  shall  be  no  superfluity  to  store  away  fat,  we  find  by 
analysis  that  the  milk  of  the  mare  has  little  or  no  butter,  in  fact 
only  traces  of  it,  in  its  composition.*  What  a  lesson  in  the  animal 
economy  is  here  given,  and  what  a  practical  illustration  of  the  re- 
quirements of  the  young  of  that  and  other  animals  1 

"Again,  it  may  be  contended  that  among  the  beautiful  children 
we  see  on  every  hand,  there  is  no  want  of  those  who  are  fat  and 
hearty.  It  is  not  fat  we  want — it  is  bone  and  muscle — with  so 
much  fat  only  as  shall  give  firmness  to  the  flesh  and  plumpness  to 
the  figure.  Fat,  although  it  enters  intimately  into  union  with  the 
other  component  parts  of  bone  and  muscle,  cannot  be  transformed 
either  into  the  inorganic  constituents  of  bone  or  teeth,  or  into  mus- 
cular fiber ;  these  must  be  contained  in  the  food  consumed,  in  the 
first  place,  and  thence  transferred  to  the  blood. 

"  How  necessary,  then,  how  important  it  is,  if  we  expect  to  give 
strength  and  vigor  to  the  consitution,  that  the  food,  in  the  first  years 
of  infancy  and  childhood,  when  the  formative  process  is  going  on, 
should  receive  some  further  attention  than  has  hitherto  been  given 
to  it;  and  if  our  youth, — if  our  young  females  have  hitherto  been 
deprived  of  the  necessary  constituents  for  the  full  development  of 
every  portion  of  the  body, — can  we  wonder  that  a  woman  should  be 
the  delicate  and  fragile  being  she  is,  or  that  by  the  decay  which 
assails  the  teeth  in  early  life,  she  should  be  deprived  of  an  ornament 
of  so  much  value  ?  If  this  state  of  things  can  be  altered, — if  the 
physical  constitution  of  woman  in  America  can  be  saved  from 
further  degeneracy, — a  purpose  may  be  effected,  of  consequence 
even  in  a  national  point  of  view ;  for  it  is  to  the  healthy  and  vigor- 

*  Analysis  of  mare's  milk. 

Water 896-3 

Butter traces. 

Casein 16-2 

Sugar  of  milk,  extractive  matters,  and  fixed  salts 87-5 

1000- 


DISEASES   OF   THE    TEETH.  187 

ous  constitution  of  woman  that  we  must  look  for  a  race  of  hardy, 
vigorous,  and  enterprising  freemen. 

"  In  conclusion,  I  would  briefly  state  that  this  is  a  matter  in 
which  professional  aid  can  avail  little ;  it  lies  at  the  door,  and  must 
be  the  work  of  parents  generally.  It  is  for  them  to  understand  the 
great  value  to  be  attached  to  the  food  on  which  their  children  sub- 
sist— that  it  shall  be  wholesome  and  nutritious,  and  abounding  in 
the  earthy  compounds  so  absolutely  necessary  to  their  proper  de- 
velopment. If  the  chief  articles  of  food  have  hitherto  consisted  of 
compounds  made  of  superfine  flour,  corn-meal,  and  the  fat  of  meat, 
let  there  be  substituted  in  their  stead,  bran-bread,  milk,  eggs,  the 
lean  of  meat,  and  potatoes ;  let  more  attention  be  given  to  the  nu- 
trient quality  of  the  food  ;  let  there  be  no  deficiency  of  those  articles 
containing  the  earthy  material,  that  the  bones  and  teeth  shall  not  be 
deficient  in  those  constituents  so  necessary  in  their  composition  and 
structure  ;  and  I  should  be  inclined  to  hope  that  the  evils  which 
now  exist  will  be  lessened,  and  the  physical  organization  of  suc- 
ceeding generations  be  equal  to  that  of  any  nation  upon  earth." 

We  pass  here  from  the  consideration  of  primary  impressions  to 
the  treatment  of  caries,  as  met  with  in  the  growing  child  or  adult. 
And,  first,  we  may  spend  a  few  moments  in  considering  the  direct 
local  attention  demanded,  and  from  which  our  investigations  should 
carry  us  to  other  constitutional  relations  than  the  primary  impres- 
sions just  considered. 

Caries  of  a  tooth  differs  from  caries  of  common  bone  only  in  the 
fact  of  an  inability  to  repair  by  any  secondary  material  the  injury 
done  through  the  destructive  influences  of  the  disease, — requiring 
for  the  restoration  of  harmony  to  the  parts,  and  for  the  protection  of 
the  exposed  susceptible  dentine,  a  mechanical  treatment.  The  opera- 
tion demanded,  being  one  of  everyday  performance,  and  withal  one 
urging  man  to  the  attainment  of  skill,  through  the  pecuniary  reward 
its  successful  accomplishment  offers,  has  given  to  this  department 
of  operative  surgery  a  degree  of  skill  and  perfection  attained  by  few 
others;  and  yet,  is  this  class  of  operations  embraced  within  a  few 
such  simple  principles,  that  any  practitioner,  with  an  ordinary  amount 
of  ingenuity,  has  only  to  practice  to  become  skillful. 

The  local  treatment  of  carious  teeth  consists  in  cutting  from  the 
cavity  of  decay  all  dead  and  dying  matter,  and  after  well  cleans- 
ing and  disinfecting  the  part,  replacing  that  removed,  with  some 
unirritating  and  indestructible  material. 


188 


ORAL  DISEASES  AND   SURGERY. 


The  first  step  in  the  operation  consists  in  getting  at  the  disease. 
This  in  many  eases  is  quite  easy  enough,  the  cavity  lying  so  exposed 
that  it  is  only  necessary  to  have  the  patient  open  the  mouth  to  see  it. 
In  other  instances,  and  these  much  the  most  numerous,  the  decay 
lies  in  such  position  that  much  cutting  and  filing,  and  it  may  be 
wedging,  are  necessary  to  the  exposure.  This  matter,  to  be  prop- 
erly appreciated,  must  be  studied  in  connection  with  the  individual 
cavities. 

Teeth  are  filled  or  stopped  with  various  materials,  —  gold,  tin 
foil,  amalgam,  and  tooth-bone  being  the  principal  agents  employed. 

Fig.  34. — Porms  of  Chisels  used  in  Dentistry. 


Of  these,  by  far  the  best  is  gold,  and  after  this  the  tin ;  the  two 
latter  agents  being  not  at  all  reliable,  and  only  perhaps  allowable 
where,  from  the  extent  and  character  of  the  decay,  a  tooth  must  be 
filled  with  a  plastic  material  or  otherwise  sacrificed.     It  is  as  easy 


DISEASES   OF  THE    TEETH.  189 

to  fill  a  tooth  with  amalgam  or  with  tooth-bone  as  it  would  be  to 
fill  it  with  putty. 

The  instruments  employed  for  filling  teeth  are  very  numerous  and 
;  varied,  each  operator  possessing  certain  favorite  styles ;  but  the 
1  instruments  absolutely  necessary  to  the  performance  of  the  opera- 
I  tion  are  really  —  as  in  all  other  operations — very  few  and  very 
;    simple. 

In  the  first  place,  it  being  necessary  to  expose  the  cavity,  chisels 
and  files  are  required.  Chisels  are  made  straight,  curved,  and  at 
right  angles.  An  accurate  idea  of  what  they  are  may  be  derived 
by  an  examination  of  the  drawing. 

Files. — Files  are  of  every  coneeivable  form. 

Fig.  35. — File,  with  Carrier. 


Fig.  35  represents  a  carrier  having  in  it  a  straight  file,  such  as  is 
used  for  the  separation  of  the  first  six  anterior  teeth.  A  modifica- 
tion of  such  a  straight  file,  much  used,  is  one  with  a  curved  and 
convex  face.  Files,  cut  on  long  shanks,  with  a  curve  to  clear  the 
lips,  are  used  for  the  back  teeth  ;  these  are  made  rights  and  lefts. 
The  straight  file  is  seldom  used  in  a  carrier,  the  fingers  being  found 
the  more  convenient  means. 

A  cavity  exposed,  its  excavation  or  cleansing  is  the  next  step ; 
for  the  accomplishment  of  this  operation  in.struments  called  exca- 
vators are  necessary.  These,  like  the  chisels  and  files,  are  various 
in  pattern ;  yet,  whatever  the  peculiarity,  they  are  only  modifica- 
tions of  two  elementary  styles,  which  two  styles  are  used  principally 
.by  every  dentist,  and  are  known  as  the  hoe  and  hatchet  excavators, 
the  one  cutting,  when  pulled  toward  the  operator,  hoe-like ;  the  second 
represented  by  the  cutting  edge  of  the  ordinary  hatchet. 

Drills. — The  rose  drill  is  a  favorite  instrument  with  the  dentist. 
These  are  of  various  sizes,  and  when  sharp,  will  cut  out  a  cavity  on 
the  grinding  face  of  a  tooth  very  perfectly  and  very  rapidly. 

The  spear-shape,  a  modification  of  the  rose,  is  much  used. 

A  tooth,  to  be  properly  excavated,  must  not  only  have  every 
particle  of  diseased  matter  removed,  but  the  cavity  must  be  made  of 
such  form  that  it  will  retain  the  material  to  be  impacted,  and  not 


190 


ORAL  DISEASES  AND  SURGERY. 


Fig.  36. — Hoe  Excavators  and  Modifications. 

«=  ==)  ^    _)L==Jt==J   (l^ -^ ^L=.  =J  11=  J 


f^.Sr^h 


n  n  n  n  r 


Fig.  37. — Hatchet  Excavators  and  Modifications. 


O   Q 


DISEASES   OF   THE   TEETH. 


191 


Fig.  38. — Rose  Drills  and  Spear  Drills. 


192  ORAL  DISEASES  AND  SURGERY. 

only  this,  but  it  must  retain  it,  while  being  of  a  shape  that  every 
portion  of  the  walls  can  be  gotten  at  with  equal  facility.  In  other 
words,  the  cavity  should  not  be  larger  than  its  inlet  or  margin; 
should  it  be  so  shaped,  and  should  the  material  employed  to  fill  it 
be  either  of  the  foils,  such  filling  is  most  apt  to  be  imperfect.  Ir- 
regular or  ragged  edges  are  not  to  be  allowed.  Good  joints,  or 
union  between  the  metal  and  teeth,  cannot  possibly  be  effected  under 
such  circumstances  ;  hence,  an  operation,  otherwise  good,  becomes 
of  little  avail.  Also,  it  is  important  that  no  sulci  or  sharp  angles 
should  exist  within  the  cavity,  but  every  part,  if  possible,  is  to  be 
rounded  and  regular. 

FILLING. 

Gold,  the  best  material  to  be  employed,  is  used  in  two  different 
forms ;  prepared  either  as  a  leaf  or  as  a  spongy  mass. 

Gold  Foil  or  Leaf  Gold. — The  manufacture  of  leaf  gold,  or  foil, 
must  be  an  exceedingly  nice  manipulation,  seeing  that  so  many  have 
undertaken  it,  and  yet  so  few  have  succeeded  in  satisfying  the 
dentist.  Some  gold  foil  is  exceedingly  adhesive,  so  much  so  indeed 
that  with  serrated  instruments  it  can  readily  enough  be  stuck  piece 
to  piece,  or  welded.  In  this  form  it  is  now  most  commonly  used, 
and  may  be  quite  as  easily  attached  and  built  upon  the  plane  sur- 
face of  a  metal  dollar  as  within  the  cavity  of  a  tooth.  To  effect 
such  result,  it  is  only  necessary  to  keep  the  parts  and  metal  per- 
fectly dry,  and  to  use  instruments  with  sharply-serrated  points.  A 
fault,  however,  not  unfrequently  attached  to  this  adhesive  gold,  is 
its  want  of  softness  or  ductility.  Unadhesive  gold  foil,  employed 
entirely  by  some  operators,  is  made  to  support  itself  within  a  cavity 
by  a  process  of  wedging  ;  in  this  form  it  is  used,  either  rolled  up  as 
cylinder,  or  otherwise  as  pellets. 

Gold  foil  comes  into  the  market  done  up  in  books — these  books 
being  numbered  from  4  to  35.  The  number  signifying  the  weight 
by  grains  of  each  leaf.  Of  these  different  numbers,  some  prefer  one, 
some  another;  it  is  perhaps  a  matter  of  choice  rather  than  dif- 
ference. 

Sponge  Gold. — This  preparation,  as  implied  in  its  name,  comes 
in  the  form  of  a  sponge  or  porous  mass.  It  is  most  adhesive,  and 
if  kept  perfectly  dry  during  the  process  of  manipulation,  can  be  at- 
tached particle  to  particle,  until  a  tooth,  however  broken  and  imper- 
fect, can  have  its  outlines  perfectly  restored.  To  use  it,  instruments, 
as  employed  with  foil,  sharply  serrated,  are  necessary;  and  the 


DISEASES   OF   THE    TEETH.  193 

portion  of  the  mass  to  be  employed  is  to  be  separated  or  picked  into 
small  pieces  by  the  employment  of  instruments  rather  than  the 
moist  fingers.  A  large  piece,  or  a  bulk  of  size  sufficient  to  retain  its 
place  in  a  cavity,  is  to  be  first  introduced  and  worked  into  a  solid 
mass ;  to  this  first  piece  particle  after  particle  is  to  be  attached  until 
the  cavity  is  filled.  It  is  a  much  more  tedious  preparation  to  work 
than  the  foil,  and,  for  a  perfect  operation,  demands  much  more  skill, 
and  infinitely  more  patience. 

Gold,  as  a  preparation  for  filling  teeth,  while  the  most  perfect 
article  employed,  is  yet  not  without  its  objections.  It  is,  unhappily 
for  this  purpose,  an  admirable  conductor  of  thermal  changes,  and 
when  used  in  close  proximity  to  the  pulp  of  a  tooth,  not  unfrequently 
so  irritates  it  as  to  result  in  its  inflammation  and  death.  Another 
objection  is  its  color. 

Tin  Foil. — This  is  simply  purified  tin  beaten  into  thin  leaves. 
It  is  worked  precisely  as  gold  foil,  and  answers,  to  an  extent,  the 
same  purpose.  It  is  a  softer  metal,  and  less  capable  therefore  of 
resisting  the  wear  and  tear  of  mastication.  It  is  still  more  ob- 
jectionable in  color  than  gold,  but  possesses  an  advantage  over  it  in 
being  a  less  sensitive  thermal  medium.  It  is  also  comparatively 
inexpensive. 

Amalgam. — This  is  a  preparation  of  silver  and  tin  amalgamated 
with  mercury.  It  is  made  by  melting  together  varying  proportions 
of  the  two  first  named  metals,  say  equal  parts,  or  four  parts  of  silver 
to  six  of  the  tin — different  persons  having  different  formula — and, 
when  thus  united,  is  comminuted  by  the  file,  and  put  aside  for  use 
when  needed. 

To  make  an  amalgam,  or  paste  filling,  as  it  is  as  frequently  called, 
take  a  portion  of  these  filings,  enough  to  correspond  with  the  size 
of  the  cavity  to  be  filled,  place  them  in  some  convenient  vessel,  add 
a  small  quantity  of  mercury,  rub  the  mass  together  for  a  few 
moments,  and  the  solid  grains  will  be  found  to  have  disappeared. 
Add  now  to  the  amalgam  a  few  drops  of  deliquesced  chloride  of 
zinc,  and  again  rub  the  whole  together.  As  a  result,  the  bottom  of 
the  vessel  will  be  covered  with  a  dirty,  black  pasty  mass,  while  the 
amalgam,  robbed  of  its  impurities,  will  present  itself  as  a  fluid  ball 
of  frost-white  silver.  The  next  step  is  to  take  this  ball,  and,  envelop- 
ing it  in  buckskin,  cotton  cloth,  or  linen  stuff,  press  out,  with  for- 
ceps, the  excess  of  mercury ;  the  result  is  now  a  semi-solid  mass, 
which  is  the  preparation  to  be  used  in  the  cavity  of  the  tooth.  To 
introduce  this  material,  it  is  only  necessary  to  thoroughly  dry  the 

13 


194  ORAL  DISEASES  AXD   SURGERY. 

cavity  with  bibulous  paper  or  other  absorbing  material — supposing 
the  cavity  to  have  been  previously  prepared — and  with  any  conven- 
ient instrument  press  the  paste  into  place.  A  few  hours,  and  it 
will  be  found  to  have  become  as  hard  as  the  tooth.  It  may  now 
be  dressed  and  polished,  and  the  operation  is  thus  completed. 

Osteoplastic  or  Tooth-bone. — This  is  a  preparation  of  oxide  of 
zinc,  silex,  titanium,  and  borax,  and  is  in  the  market  in  the  form  of  a 
whitish,  coarse  powder.  To  use  it,  a  small  quantity  of  the  material 
is  mixed  with  a  watery  solution  of  the  chloride  of  zinc,  and  in  the 
form  of  a  paste,  thus  produced,  it  is  plastered  into  the  cavity.  The 
most  perfect  dryness  is  necessary  to  any  success  in  its  use ;  and,  if 
possible,  the  filling  is  to  be  protected  from  the  fluids  of  the  mouth 
for  a  period  of  several  days.  This  can  be  accomplished, — first,  by 
protecting  and  shielding  the  mass  placed  in  the  tooth  while  in  the 
act  of  setting  or  hardening,  through  the  careful  employment  of  nap- 
kins and  bibulous  paper  ;  and,  second,  by  dissolving  in  chloroform  a 
sufficient  quantity  of  gutta-percha  to  make  a  thin  paste.  This, 
dropped  from  the  point  of  an  instrument  over  the  filling,  will  per- 
fectly coat  it,  and  remain  adherent  for  several  days,  or  quite  as  long 
as  is  necessary. 

Gutta-percha. — This  agent  is  not  unfrequently  used  as  a  tem- 
porary stopping.  It  is  introduced  precisely  as  the  amalgam,  being, 
however,  first  warmed  in  the  flame  of  an  alcohol-lamp.  In  its  place 
it  is  often  found  quite  useful ;  I  have  seen  these  temporary  fillings 
preserve  a  tooth  for  years, — it  is  not  well,  however,  to  so  trust 
them.  A  preparation,  much  used  as  a  temporary  filling,  consists  of 
gutta-percha,  quicklime,  quartz,  and  feldspar ;  it  is  known  as  Hill's 
stopping.  It  can  be  purchased  at  any  of  the  depots  at  a  very  reas- 
onable price. 

The  process  of  filling  a  tooth,  whatever  may  be  the  material  em- 
ployed, is,  unless  when  complications  exist,  a  matter  merely  of 
mechanical  skill.  As-  before  remarked,  it  requires  only  practice  to 
become  a  proficient,  that  is,  taking  it  for  granted  the  manipulator 
has  mechanical  ability.  Complications,  associated  with  the  sy.stem 
at  large,  are,  however,  so  frequent  in  occurrence  that  it  has  now  be- 
come a  recognized  fact  that  a  general  medical  education  is  as  neces- 
sary for  the  proper  appreciation  and  understanding  of  this  depart- 
ment of  practice  as  for  that  of  any  other.  Hence  the  great  progress 
which  all  writers  are  called  on  to  chronicle,  and  which  has  in  its 
results  been  of  such  great  gain  to  the  public  at  large. 

For  a  continued  consideration  of  this  matter,  the  treating  and 


DISEASES   OF   THE    TEETH. 


195 


filling  of  individual  cavities,  the  preparation  of  artificial  teeth,  etc., 
the  reader  is  referred  to  the  various  text-books  on  dental  surgery. 


Fig.  39. — Instruments  employed  in  Introducing,  Condensing,  and 
Polishing  Gold  and  Tin  Fillings. 


196 


OBAL   DISEASES  AND   SURGERY. 


As  caries  of  the  teeth  is  seen  to  have  a  strong  exciting  cause  in 
the  influence  of  local  irritants,  it  naturally  occurs  that  such  sources 
of  trouble  are  to  receive  a  proper  degree  of  attention;  hence  the  em- 
ployment and  use  of  dentifrices  and  washes. 

In  the  treatment  of  any  case  of  dental  caries  which  may  present 
itself,  the  careful  practitioner  first  endeavors  to  satisfy  himself  of  the 
causes,  constitutional  and  local,  influencing  the  diseased  condition; 
of  the  constitutional  causes,  all  aS"ect  the  integrity  of  the  teeth  which 
are  deteriorative  to  the  system  at  large.  Unhappily  for  the  dental 
organism,  primary  unhealthy  impressions  made  upon  the  teeth, 
Avhile  in  their  formative  or  pulpy  state,  are  apt  to  influence  more  or 
less  their  character  for  life,  just  as  certain  of  the  exanthemata — 
variola,  for  instance — occurring  at  such  period,  is  so  apt  to  impress 
permanent  pittings  upon  the  enamel. 

Unhealthy  parents  cannot  by  possibility  beget  perfectly  healthy" 
oflPspring.  Here  is  a  great  primary  antagonist.  The  teeth,  how- 
ever, are  living,  and  consequently  changing  bodies :  particularly  is 
this  true,  physiologically,  of  young  teeth.  Constitutional  treatment 
may  thus  do  service  even  as  every  molecule  of  tooth  structure  is 
concerned ;  such  treatment  would  of  course  be  longer  in  receiving 
apparent  response,  as  must  be  evident,  when  considering  the  rela- 
tive low  vitality  of  these  organs,  than  treatment  directed  to  the  pro- 
duction of  an  impression  on  the  soft  parts,  or  on  common  bone ; 
yet,  because  a  tooth  is  an  organized  body,  because  it  has  innervation 
and  circulation,  such  treatment  must,  to  a  greater  or  less  extent, 
be  felt. 

A  first  indication  calls  for  the  consideration  of  causes  interfering 
with  the  proper  vitality  of  any  denture  coming  under  observation. 


DISEASES   OF   THE   TEETH.  I97 

Hereditarily,  or  how  otherwise   deteriorated,  duty  to  the  patient 
demands  such  consideration  of  the  case. 

We  will  suppose  a  trouble  to  be  hereditary.  Here,  if  we  can 
find  in  a  patient  the  observable  existence  or  continuance  of  habits, 
either  of  organic  functional  irregularity,  or  of  animal  habits  common 
to  the  parent,  and  which  is  to  be  esteemed  of  deteriorating  import, 
our  first  attention  is  to  be  directed  to  a  correction.  The  parent  may 
have  been  specifically  diseased,  let  us  suppose,  by  his  parent,  and 
thus  the  bad  teeth  of  both  father  and  child  lie  in  a  venereal  molec- 
ular impression.  Here  a  predisposing  cause  would  have  come  from 
and  would  be  still  residing  in  a  syphilitic  condition.  Granting,  then, 
that  such  molecules,  still  living,  are  impressible,  would  judgment 
not  direct  a  primary  treatment  to  the  production  of  an  impression  in 
such  direction?  I  have  treated  many  a  child,  for  skin  and  other 
diseases,  where  the  affliction  was  an  hereditary  venereal  transmission, 
and  I  never  thought  of  directing  medication  otherwise  than  in  recog- 
nition of  such  a  transmission;  and  satisfied,  as  every  medical  man 
must  be,  that  the  circulatory  fluid  permeates  tooth  structure,  I  treat 
venereally  deteriorated  teeth  on  the  same  common  principle,  and  have 
found  in  the  result  that  measure  of  success  which  has  justified  the 
conclusions.  In  other  words,  I  have  prolonged  the  life  and  health 
of  such  organs,  just  as  is  prolonged  the  life  and  health  of  the  patient 
upon  whose  molecules  are  impressed  the  fiat  of  the  tubercles  of 
phthisis.  Such  a  treatment  consists,  however,  not  in  administering 
specific  or  supposed  specific  remedies,  but  in  viewing  the  system  as 
laboring  under  depressing  influences,  either  of  a  general  or  special 
local  signification, — this  fact  is  most  important  to  recognize. 

A  child  may  have  its  molecules  deteriorated  by  a  transmitted 
mercurial  impression,  or  a  parent  may  have  been  an  inebriate,  and 
thus  have  debased  his  child  in  himself.  The  results  of  an  excessive 
venery  may  have  been  transmitted.  A  mother,  from  lack  of  nourish- 
ing material,  may  have  degenerated  her  offspring.  These  causes  of 
transmitted  ills,  the  appreciable  ones,  I  may  say,  are  many, — all 
must  recognize  them. 

Improper  diet  to  the  developing  child,  as  we  have  so  fully  studied, 
is  plainly  enough  a  cause  of  bad  teeth.  The  state  of  health  of  such 
a  developing  child  has  its  influence;  indeed,  so  marked  is  this  that, 
by  an  observation  of  teeth  belonging  to  the  various  periods  of  life, 
one  can  easily  enough  trace  constitutional  variations,  for  just  as  at 
difi'erent  periods  the  functions  of  organic  life  were  healthily  or  un- 
healthily performed,  so  we  find  the  disturbances  written  in  the  char- 


198  ORAL   DISEASES  AND  SURGERY. 

acter  of  the  teeth  belonging  to  the  period.  More  expressive  even 
than  this  is  the  fact  that  the  deciduous  teeth  mark,  in  the  periods  of 
their  solidification,  the  health  of  the  mother. 

That  the  teeth,  in  their  formative  state,  partake  of  the  healthy  or 
unhealthy  condition  of  the  system  at  large,  all  observers  now  admit. 
But  here,  unfortunately,  the  matter  has  been  left,  most  practitioners 
acting  on  the  premises  that  such  impressions  are  never  to  be  altered. 
At  such  a  conclusion  it  is  impossible  not  to  express  surprise.  Who, 
in  his  own  person  or  in  the  persons  of  friends,  has  not  remarked  the 
varying  conditions  of  the  health  of  the  teeth  ?  Up  to  the  age  of 
sixteen  I  was  myself  a  martyr  to  toothache;  yet,  about  that  period, 
a  change  occurred,  since  which  time  I  have  had  no  trouble.  Is  it 
suggested  that  the  teeth  may  have  been  filled  ?  That  would  be  very 
true,  but  certain  of  the  fillings  came  out  years  ago  and  have  never 
been  replaced,  yet  are  the  teeth  quite  as  good  as  those  in  which  the 
operations  remained. 

Similar  instances  exist  in  profusion,  and  yet  the  lesson  seems 
unheeded.  There  is  a  constitutional  treatment  for  the  carious  tooth 
as  there  is  for  the  carious  maxilla,  and  from  a  common  stand-point 
should  the  diseases  of  both  be  viewed.  It  is  not  of  course  every 
case  of  a  carious  bone  that  demands  a  constitutional  treatment, 
neither  is  it  so  with  the  teeth ;  the  source  of  offense  in  the  one,  as 
in  the  other,  may  be  strictly  local  in  its  character;  but  ill  success 
must  ever  that  practitioner  have  who  has  not  the  inclination  to 
look  for  a  primary  lesion  outside  of  things  strictly  local  in  sig- 
nification. 

A  principal  exciting  cause  of  decay  in  the  teeth  is  found  in  a  lack 
of  cleanliness ;  most  persons,  without  recognizing  it,  are  careless  in 
their  attention  to  these  organs.  Another  exciting  cause  lies  in  injury 
done  by  an  improper  use  of  them, — the  biting  of  hard  substances,  as 
rock-candy,  cracking  of  nuts,  etc.,  breaking  in  this  way  the  enamel, 
and  thus  exposing  to  irritation  the  higher  organized  and  suscep- 
tible dentine.  A  lack  of  proper  exercise  for  the  organs  is  another 
prolific  source  of  disease ;  witness  the  expression  of  this  in  the 
teeth  of  swill-fed  cows.  Children  and  adults  should  use,  in  part  at 
least,  food  which  requires  mastication  for  its  comminution.  The 
lodgment  of  decomposing  particles  in  the  sulci,  and  between  the 
teeth,  should  be  strictly  guarded  against.  To  this  end  the  quill  or 
pick  of  wood  or  brush  should  be  frequently  and  freely  employed. 
Certain  irritative  conditions  of  the  oral  fluids  should  receive  atten- 
tion ;  thus,  whether  this  fluid  be  too  acid  or  too  alkaline,  it  is  alike 


DISEASES   OF   THE    TEETH.  199 

injurious,  and  should  receive  correction.  A  piece  of  common  litmus 
paper  is  always  at  command  for  these  analyses,  and  the  conditions 
of  the  fluid  can  be  ascertained  at  any  time  in  a  single  moment. 

An  inspissated  mucus  is  another  source  of  offense  to  the  teeth. 
In  some  mouths  this  is  so  persistent  and  offensive  in  character  as 
plainly  enough  to  point  to  its  constitutional  origin.  To  correct  it  I 
have  always  placed  most  reliance  on  the  exhibition  of  the  mineral 
acids,  assisted  by  a  free  course  of  salt  bathing.  As  a  local  antago- 
nist there  is  nothing  better  than  an  astringent  acidulated  wash,  con- 
joined with  the  permanganate  of  potass. 

A  very  good  formula  is  as  follows : 

B. — Decoct,  quercus  (fort),  ^vi; 
Acid,  sulph.  aromat.  5i ; 
Potass,  permang.  gr.  xx.     M. 

This  may  be  used  in  full  strength,  or  it  may  be  diluted,  pro  re 
nata.  Conjoined  with  this  treatment,  the  aqua  chlorinat.  of  Watson 
may  be  used ;  fifteen  drops  given  once  a  day  for  a  few  days  will 
correct  all  disagreeable  odor,  and  render  the  breath  sweet  and 
pleasant. 

In  an  acid  condition  of  the  oral  fluids,  where  local  medication 
seems  necessary,  a  very  pleasant  formula  is  as  follows: 

B. — Tinct.  capsici,  5ijj 
Tinct.  pyrethri,  ^i ; 
Tinct.  cinchonse, 
Tinct.  quillai,  aa  ^ij  ; 
Aqua  calcis,  §iv ; 
01.  gaultherise,  q.  s.     M. 

This  may  be  used  on  the  brush  as  an  ordinary  wash,  and  will  be 
found  quite  agreeable. 

An  alkaline  local  indication  may  very  well  be  met  by  a  prescrip- 
tion like  the  following: 

B. — Tinct.  capsici  comp.  5i; 
Acid,  sulph.  aromat. 
Aquai  cologn.  aa  ^ij  ; 
Spts.  vin.  Gal.  ^iij  ; 
Tinct.  quillai,  5ij  ; 

01.  lim.  vel  verbena  vel  gaultherise,  q  s.    M. 
Sig.  Use  pure  or  dilute,  as  most  agreeable. 


200  ORAL  DISEASES  AND    SURGERY. 

Tooth  powders  are  necessary  to  proper  cleanliness.  A  very  good 
combination  for  everyday  use  may  be  prepared  as  follows  : 

B. — Os  sopiae  pulv.  ^i; 
Carbo  ligni  pulv.  5i  I 
Coral  pulv.  Jss ; 
Lap.  pumic.  pulv. 
Cretae  prep,  aa  5i ; 
Iridis  flor.  pulv.  ^i ; 
01.  limon.  q.  s.     M. 

The  objection  to  such  a  combination,  that  certain  of  its  ingredi- 
ents are  insoluble  in  the  fluids  of  the  mouth,  does  not,  in  my  ob- 
servation, hold  good.  It  will  keep  the  teeth  very  clean,  and,  like  all 
powders,  should  have  the  frequency  of  its  use  modified  by  the  end 
to  be  accomplished.  Of  course,  like  all  other  good  things,  it  could 
easily  enough  be  abused. 

Castile  soap  is  an  excellent  article  for  occasional  use.  Its  too 
continuous  employment,  however,  is  apt  to  induce  a  spongy,  relaxed 
condition  in  the  gums. 

Floss  silk,  well  waxed,  should  be  used  daily  between  the  teeth,  or 
where  there  is  much  tendency  to  the  collection  and  retention  of 
particles,  it  may  be  employed  unwaxed,  and  being  wet,  enveloped 
in  pumice  or  cuttle-fish  powder.  Thus  prepared,  it  can  be  made  to 
keep  the  approximal  surface  very  clean.  Common  lamp-wick  is 
even  a  better  material  than  silk,  if  the  spaces  are  open  enough  to 
permit  its  use ;  it  is  not  nearly  so  apt  to  irritate  the  gums. 

Caries  of  a  tooth  has,  as  its  sequelae,  sensibility  of  the  irritated 
and  inflamed  dentine ;  exposure  of  the  dental  pulp,  accompanied  by 
the  pains  of  irritation  and  inflammation ;  periodontitis  not  unfre- 
quently ;  reflex  neuralgic  pains  ;  and,  in  occasional  instances,  epulo- 
fungoid  excrescences  from  the  exposed  pulp. 

The  prophylaxis  to  these  conditions  consists  in  checking  and 
controlling  the  caries  on  its  earliest  appearance. 


CHAPTER    X. 


DISEASES    OF   THE    TEETH. 


ODONTALGIA. 


Under  this  common  head  we  shall  consider  all  the  various  pains 
in  the  teeth,  however  induced.  The  term  comes  from  the  two  Greek 
roots,  odous,  a  tooth,  and  algos,  pain — odontalgia,  toothache,  or  pain 
in  a  tooth. 

The  causes  of  toothache  may  be  classed  under  the  following 
heads : 

1.  Sensitive  dentine. 

2.  Direct  or  indirect  exposure  of  the  pulp  to  sources  of  irritation, 

3.  A  diseased  state  of  the  periodonteum. 

4.  Confinement  of  pus  and  gas  in  the  pulp  cavity. 

5.  Granules  of  osteo-dentine  in  the  pulp. 

6.  Sympathy. 

1.  Recession  and  absorption  of  the  gum  and  alveolus. 

1st.  Sensitive  Dentine. — Some  teeth,  immediately  upon  the  break- 
ing down  of  the  enamel  and  the  consequent  exposure  of  the  dentine, 
become  exceeding  sensitive,  or,  in  other  words,  exhibit  themselves 
as  peculiarly  susceptible  to  the  influence  of  irritating  agents.  This 
impressibility  is  caused  in  some  instances  by  the  exposure  of  the 
enamel  membrane,  in  others  by  an  excess  in  the  organic  elements  of 
the  tooth  ;  from  the  endosteum,  and  perhaps  periosteum,  nerve  fila- 
ments permeate  more  or  less  completely  all  the  intertubular  spaces 
of  such  teeth,  and  thus  in  proportion  to  the  surface  presented  is  the 
existing  irritability.  The  pain,  under  these  circumstances,  is  seldom, 
perhaps  never,  unless  the  irritation  is  carried  to  the  pulp,  at  all 
acute,  but  rather  dull  and  annoying,  and  influenced  almost  wholly 
by  the  contact  of  irritating  substances.  Thus  sweets,  taken  into 
the  mouth,  or  cold  or  hot  drinks,  or  acids,  will  at  once  create  pain. 
Sometimes  the  discomfort  arising  from  sensitive  dentine  is  con- 
tinuous.   In  these  cases  the  cause  must  be  looked  for  in  some  irrita- 

(201) 


202  ORAL   DISEASES  AND   SURGERY. 

tive  condition  existing  in  the  oral  fluids.  These  may  be  too  acid, 
or  otherwise  too  alkaline.  Test  Avith  the  litmus,  and  prescribe 
accordingly. 

Medicinal  obtunders  are  by  some  highly  recommended  as  direct 
applications  to  teeth  thus  sensitive,  but  their  employment  must 
always  be  made  with  much  caution.  Cobalt,  arsenious  acid,  chloride 
of  zinc,  chromic  acid,  acid  nitrate  of  mercury,  are  preparations  em- 
ployed. The  danger  arising  from  their  use  is  the  too  common  ill 
effect  upon  the  dental  pulp,  this  organ  being  very  apt  to  be  irritated 
and  inflamed  by  absorption  of  the  obtunding  agent.  My  own  im- 
pression is  that  such  agents  as  are  cscharotic  in  their  qualities 
should  seldom,  if  ever,  be  employed.  In  place,  it  is  much  better  to 
apply  chloroform,  aconite,  or  preparations  of  kindred  character. 
Better  still,  avoid  the  use  of  the  irritating  agent ;  or,  if  this  is  not 
practicable,  antagonize  its  irritative  quality  through  an  adapted  pre- 
scription. 

A  permanent  cure  for  sensitive  dentine  is  to  be  found  in  plugging 
the  cavity,  and  this  is,  without  doubt,  the  proper  treatment.  Bur- 
nishing down  the  tubules  is  another  remedy  proposed  ;  this  fre- 
quently answers,  temporarily,  a  very  good  purpose. 

The  excavation  of  a  sensitive  cavity  is  sometimes  most  unbeara- 
ble. It  is  better,  however,  that  the  patient  should  endure  the  suffering 
than  risk  destroying  the  vitality  of  the  tooth  ;  or,  if  such  endurance 
is  impossible,  it  is  better  that  he  should  be  etherized.  A  very  few 
cuts  of  a  sharp  excavator  will  generally  be  sufficient  to  clear  out  the 
debris,  and  if  the  instrument  is  used  with  boldness  and  skill,  the 
pain  is  very  quickly  over.  Etherization  needs  not,  of  course,  be  car- 
ried to  any  very  profound  extent. 

To  distinguish  between  the  common  sensibility  of  exposed  den- 
tinal structure  and  sensibility  arising  from  exposure  of  the  dental 
pulp,  it  is  only  necessary  to  use  an  instrument  in  examination  of 
the  cavity.  If  the  trouble  pertains  alone  to  the  dentine,  all  parts 
touched  will  be  found  alike  sensitive.  If  the  nerve  or  pulp  is 
exposed,  the  pain  to  touch  increases  as  the  instrument  approaches 
the  deepest  part  of  the  cavity,  or  the  seat  of  the  exposure,  such  seat 
being  not  unfrequently  in  cornua,  which  may  run  quite  near  to  the 
surface. 

2d.  Direct  or  Indirect  Exposure  of  the  Pul]:)  to  Sources  of  Irri- 
tation.— Reference  to  the  anatomy  and  relations  of  the  dental  pulp, 
exhibits  it  as  a  body  composed  of  the  most  delicate  connective  tissue, 
in  which  ramify  nerves,  arteries,  and  veins.     This  body  is  lodged 


DISEASES   OF   THE    TEETH.  203 

in  a  bony  cavity,  sufficient  only  in  size  for  its  comfortable  accommo- 
dation, and  for  the  halitus  or  fluid  which  surrounds  it.  Any  undue 
congestion  will  therefore  at  once  be  perceived  to  result  in  a  pressure, 
and^vhich,  from  the  presence  of  nerve  matter,  must  yield  acute  pain. 
This  appreciated,  the  pains  resulting  from  an  irritated  pulp  must  be 
felt  to  be  alike  in  general  character. 

A  pulp  need  not,  as  suggested  in  connection  with  applications 
employed  to  obtund  sensitive  dentine,  of  necessity,  be  fairly  exposed 
to  be  the  subject  of  irritation. 

Cases  not  unfrequently  occur  where  the  plate  or  floor  of  a  cavity 
is  so  thin  and  so  altered  in  structure  that  it  will  yield  or  bend. 
In  these  instances  the  agencies  of  mastication  may  and  do  readily 
enough  force  this  plate  down  upon  the  pulp.  Asa  consequence  of 
such  pressure  we  have  irritation,  and,  it  may  be,  inflammation. 

Irritation  of  a  pulp  is  much  more  apt,  however,  to  be  associated 
with  its  exposure.  Here  everything  entering  into  the  cavity  is  a 
source  of  offense,  and  the  lesion  is  always  plainly  enough  discovera- 
ble; foreign  particles  coming  in  contact  with  such  an  exposed  pulp 
give  instant  and  perhaps  excessive  pain.  This  pain  may  quickly 
subside,  or  it  may  continue  for  hours  or  days  ;  in  the  latter  case, 
inflammation  will  be  found  to  have  established  itself. 

A  free  and  open  break  into  the  pulp  cavity  is  attended  with  much 
less  pain  in  inflammation  of  the  organ  than  more  limited  exposure. 
In  the  first  case,  the  swelling  pulp  has  plenty  of  room,  and  conse- 
quently less  pressure  is  exerted  on  the  nerve  filaments.  In  the 
second,  the  protruding  congested  organ  becomes  quickly  strangu- 
lated, and  thus  pain  of  the  most  acute  and  severe  character  is 
induced. 

The  treatment  of  an  exposed  pulp  is  of  a  twofold  character,— palli- 
ative and  radical.  The  first  consists  in  the  employment  of  soothing 
and  quieting  applications,  and  is  principally  employed  for  the  relief 
of  children.  The  second  implies  the  destruction  of  the  pulp  ;  this 
being  generally  effected  through  the  instrumentality  of  escharotic 
applications.  To  quiet  an  irritated  pulp,  a  first  attention  is  to  be 
directed  to  the  removal  of  any  and  all  sources  of  offease.  If  the 
fluids  of  the  mouth  are  irritative,  the  character  of  the  condition  must 
be  sought  for  and  corrected.  If  foreign  particles  have  found  their 
way  into  the  cavity  of  decay,  they  are  to  be  carefully  syringed  away 
with  warm  water.  Such  attention  may  be  all  that  is  sufficient.  If 
not,  and  the  excitability  continues,  recourse  should  be  had  to  sooth- 
ing applications,— chloroform,  aconite,  and  laudanum,  in  equal  parts. 


204  ORAL   DISEASES  AXD   SURGERY. 

sometimes  act  very  happily,  particularly  in  such  cases  as  depend 
upon  excitation  unattended  with  inflammation.  Where  evidence  of 
congestion  or  vascular  excitement  of  any  grade  exist,  lead-water  and 
laudanum  will  frequently  act  like  magic.  Persulphate  of  iron  and 
tinct.  iodine,  in  similar  conditions,  are  found  sometimes  to  act  very 
happily,  constringing  the  vessels,  and  thus  breaking  up,  or  aborting, 
as  it  were,  the  congestion.  In  the  odontalgia  of  first  dentition,  it  i 
is  well  that  the  parent  should  be  provided  with  a  general  prescrip- ; 
tion.  A  very  good  one  is  as  follows,  to  be  applied  by  saturating  a 
small  piece  of  cotton  and  laying  it  loosely  in  the  cavity: 

R. — Creasotum,  gtt.  vi ; 
Tinct.  iodinii,  5i ; 
Aqua  plumbi,  5ss ; 
Chloroform, 
Tinct.  opii,  aa  5i-     M. 

Such  a  prescription  is  suggested  on  the  principle  of  Dewees'  car- 
minative, and  meets,  in  some  one  or  another  of  its  ingredients,  the 
single  or  various  indications  that  may  be  present. 

In  a  severe  inflammation  of  the  pulp,  it  may  be  necessary  to  re- 
sort to  more  indirect  medication  :  blisters  upon  the  nape  of  the  neck 
will  frequently  result  in  speedy  relief;  hot  pediluvia;  saline  cathar- 
tic medicines,  as  the  sulphate  of  magnesia ;  diaphoretics,  as  the  spirits 
of  Mindererus;  or  diuretics,  as  the  niter  preparations.  An  inflamma- 
tion of  the  dental  pulp,  if  not  too  far  advanced,  may  almost  invari- 
ably be  broken  up  by  the  administration  of  from  ten  to  forty  grains 
of  bromide  of  potassium,  the  application  of  a  mustard  poultice  to 
the  back  of  the  neck,  and  a  hot  foot  bath,  continued  from  twenty 
minutes  to  half  an  hour. 

To  destroy  a  pulp,  a  small  portion  of  the  following  maybe  laid  in 
the  cavity,  and  loosely  covered  with  wax,  or  cotton  saturated  in 
sandarac  varnish : 

R. — Acid,  arsenicum, 

Morph.  acet.  vel  morph.  sulph.  aa  grs.  x; 
Creasotum,  q.  s.  for  a  thick  paste.     M. 

Of  this  a  piece  the  size  of  a  common  pin-head  will  be  found 
quite  enough  for  the  purpose.  In  the  application  of  this  arsenical 
paste,  means  should  be  taken  to  insure  its  action  as  speedily  and 
thoroughly  as  possible.  If  too  little  is  used,  it  produces  not  the 
death  of  the  pulp,  but  an  inflammatory  action,  which  is  apt  to  involve 


DISEASES   OF   THE   TEETH.  205 

the  whole  tooth,  making  it  tender  and  irritable,  resulting,  not  un- 
likely, in  chronic  periosteal  trouble.  To  insure  a  speedy  action, 
it  is  well  to  somewhat  freely  expose  the  pulp  before  making  the  ap- 
plication. A  very  admirable  plan,  if  convenience  permits,  is  to 
prick  the  paste  into  the  organ  with  a  needle-pointed  instrument ;  a 
pulp  so  treated  in  my  own  mouth  was  thus  rendered  capable  of  a 
painless  removal  after  a  very  few  minutes,  and  without  the  slightest 
apparent  inflammatory  action  being  provoked. 

Arsenic  applied  to  a  pulp  for  its  destruction  had  better  be  re- 
moved after  twelve  or  fifteen  hours.  I  do  not  recognize  this,  how- 
ever, as  absolutely  necessary,  particularly  in  the  fully  developed 
adult  tooth ;  but  such  practice  is  not  at  all  amiss,  as  thus  the  possi- 
bility of  its  effects  on  parts  beyond  the  foramen  is  guarded  against. 

In  referring  to  the  physiological  changes  constantly  in  progress 
in  young  teeth,  and  particularly  the  deciduous  set,  the  inadvisability 
of  arsenic  as  an  application  is  at  once  made  evident.  Here  the  for- 
amina are  in  various  conditions  of  enlargement;  and  applications  of 
such  character  would  of  course  pass  at  once  through  these  to  the 
parts  beyond.  If  the  destruction  of  the  pulp  in  this  class  of  teeth 
becomes  a  necessity,  the  object  may  be  effected  by  the  continuous 
and  daily  employment  of  creasote,  to  which  has  been  added  equal 
measure  of  Monsel's  solution  of  the  perchloride  of  iron. 

A  permanent  tooth,  after  the  destruction  of  its  pulp,  can  have  the 
cavity  filled,  and  be  made,  in  the  majority  of  instances  perhaps,  quite 
as  useful  as  ever.     (See  works  on  Dental  Surgery.) 

A  cause  of  odontalgia  from  an  irritated  pulp  frequently  exists  in 
the  case  of  plugged  teeth,  from  proximity  to  the  organ  of  the  mate- 
rial used  in  the  filling.  In  these  instances  a  constant  irritation  is 
kept  up  by  thermal  impression,  induced  by  the  pi'esence  of  the  metal. 
If  inflammation  supervenes,  the  pain,  because  of  the  perfectly  in- 
closed condition  of  the  pulp,  becomes  of  the  most  acute  and  unbear- 
able character ;  relief  will  generally  be  obtained  by  the  removal  of 
the  filling  ;  or,  if  this  should  not  succeed,  the  pulp  may  be  treated  as 
above  described.  Where  several  teeth  are  in  a  state  of  irritation 
from  such  a  cause,  and  confusion  of  distinct  location  is  thereby  in- 
duced, as  is  not  unfrequently  witnessed,  the  affected  teeth  can  be 
made  clearly  to  designate  themselves  by  holding  in  the  mouth  cold 
water;  or,  what  is  even  better,  touch  each  particular  filling  with 
some  steel  instrument.  The  increase  in  sensation  will  be  thus  made 
very  marked. 

The  dental  operator  frequently  cures  such  teeth  by  introducing 


206  ORAL  DISEASES  AND  SURGERY. 

between  the  filling  and  floor  of  the  cavity  some  non-conducting  sub- 
stance,  a  piece  of  ordinary  quill,  a  particle  of  asbestos,  a  layer  of 

gutta-percha,  or  a  portion  of  the  Hill  stopping. 

Still  another  source  of  irritation  to  the  dental  pulp  is  found  in 
the  wearing  down  of  the  teeth.  This  is  particularly  observed  in 
persons  who  use  large  quantities  of  tobacco,- or  in  such  as  have  the 
upper  and  lower  teeth  directly  articulating.  Happily,  however,  in 
the  generality  of  such  cases,  nature  antagonizes  the  external  influ- 
ence by  depositing,  in  quantities  as  needed,  secondary  or  osteo-den- 
tine  within  the  pulp  cavity,  contracting  at  the  same  time  this  organ, 
so  that,  in  proportion  as  the  tooth  wears  away  on  its  cutting  face, 
the  pulp  recedes,  and  casts  out,  as  its  protection,  this  secondary 
material.  It  is  a  beautiful  and  wonderful  process  of  ofi"ense  and  de- 
fense, and  commands  our  admiration. 

In  some  cases,  however,  and  these  not  a  few,  this  reparative  or 
protective  power  does  not  seem  to  exist ;  where  this  happens,  the 
pulp  becomes,  of  course,  soon  the  subject  of  irritation.  I  have  seen, 
from  such  a  cause,  some  of  the  severest  cases  of  odontalgia.  The 
only  cure  is  to  be  found  in  the  destruction  of  the  pulp.  To  apply 
arsenical  paste  under  such  circumstances,  there  being  no  cavity  of 
decay,  it  may  be  sufficient  to  lay  it  in  the  cup-shaped  depression 
commonly  existing  on  the  cutting  faces  of  such  teeth  (the  result  of 
the  more  rapid  wearing  of  the  inner  dental  structure  over  the  outer 
enamel  wall),  keeping  it  in  place  with  a  covering  of  wax.  When  pos- 
sible, however,  it  is  much  better,  and  more  speedy  practice,  to  care- 
fully drill  an  opening  into  the  pulp  cavity,  and  with  a  delicate  needle 
pick  the  arsenic  directly  into  the  pulp.  The  death  of  the  organ  se- 
cured, it  is  to  be  removed  from  its  cavity  by  a  barb,  and  its  place 
supplied  with  gold. 

Improper  union  of  metals  in  the  filling  of  a  tooth  is  another  not 
unfrequent  source  of  irritation  to  the  dental  pulp.  Tin  foil  is  some- 
times placed  in  the  bottom  of  a  cavity,  and  the  operation  finished 
with  gold.  In  many,  not  in  all  instances,  this  composition  produces 
a  galvanic  action,  which,  if  not  removed,  will  quickly  enough  destroy 
the  pulp. 

Still  another  source  of  irritation  is  the  employment,  in  cavities 
more  or  less  in  proximity  to  the  pulp,  of  the  preparation  described 
as  tooth-bone :  the  chloride  of  zinc  used  in  the  compound  will  not 
unfrequently,  within  a  very  few  hours  after  its  application,  produce 
an  inflammation  in  the  parts  almost,  if  not  entirely,  uncontrollable; 
few  preparations  require  to  be  used  with  more  judgment. 


DISEASES   OF   THE    TEE  TIT.  207 

A  tooth  so  irritated  is  to  have  the  filling  removed,  and  pei'haps  it 
will  always  be  found  the  best  practice  to  finish  the  death  of  the  pulp 
as  speedily  as  possible.  As  a  reverse  to  this,  it  is  undeniable  that 
the  use  of  this  material  will  sometimes  prove  just  provocative  of 
sufficient  irritation  to  excite  the  secretion  of  secondary  dentine,  thus 
proving  the  best  practice  that  could  have  been  pursued. 

A  pulp  may  give  every  evidence  of  being  in  an  irritated  condition 
where  the  osseous  integrity  of  the  tooth  is  perfect,  or  seemingly  so. 
Here  the  cause  may  be  still  strictly  local,  or  it  may  be  constitutional. 
Blows  received  by  a  tooth  often  result  in  such  irritation.  Atmos- 
pheric changes  will  sometimes  account  for  the  condition.  Pieces  of 
ice  brought  and  retained  in  contact  with  teeth  of  loose  structure  are 
frequent  sources  of  such  trouble.  Cracks  in  the  enamel,  induced 
from  whatever  cause,  and  permitting  the  impression  upon  the  den- 
tine of  external  influences,  are  other  explanations.  In  a  constitu- 
tional direction,  rheumatism  is,  perhaps,  the  most  frequent  source; 
after  this,  gout.  Reflex  or  radiated  irritability  is  a  frequent  manifes- 
tation. This  is,  perhaps,  most  observable  in  the  hysterical  female. 
In  these  cases  no  special  rules  are  required.  It  is  only  necessary  to 
discover  the  cause  of  offense,  wherever  and  however  situated,  and 
to  remove  it  if  possible.  In  the  odontalgia  of  gout,  dependence 
must  be  placed  upon  the  exhibition  of  colchicum  ;  twenty  drops,  three 
or  four  times  a  day,  according  to  the  urgency  of  the  symptoms,  may 
be  given.  In  rheumatism,  I  know  few  better  combinations  than  the 
following.  Its  administration  to  be  preceded  by  a  free  purging  with 
a  saline  cathartic. 

R. — Ext.  belladonna,  grs.  vi ; 
Vin  colch.  rad.  §ss  ; 
Tinct.  guaiac.  ammoniat.  svi; 
Potass,  iod.  ^ss  ; 
Aqua  cinnamomi,  ^vi.  M. 
Sig.  To  the  adult  give  a  tablespoonful  three  times  a  day  in  a  little 
water ;  if  it  act  too  freely  on  the  bowels,  add  opium  q.  s. 

Functional  derangements  of  the  stomach  might  perhaps  deserve 
special  attention,  as  the  reflex  or  radiated  odontalgia  is  concerned. 
Any  one  who  has  ever  observed  the  relationship  existing  be- 
tween the  pneumogastric  and  third  nerve,  as  manifesting  functional 
stomachic  derangement  in  the  enlargement  of  the  pupil  of  the  eye, 
will  be  at  no  loss  to  associate  the  fifth  and  ninth  nerve.  Pure  neu- 
ralgia, as  the  term  has  common  signification,  is,  I  am  satisfied,  a 


208  ORAL  DISEASES  AND   SURGERY. 

very  rare  affection;  an  aching  nerve  will  generally  be  found  to  have 
some  lesion  outside  of  a  so-esteemed  idiopathic  condition,  and  the 
lesion  can  generally  be  discovered  by  closely  looking  after  it. 

3d.  A  Diseased  Slate  of  the  Periodonteum. — To  the  existence  of 
this  condition  I  have  before  had  occasion  to  allude.  Its  most  com- 
mon and  precedent  lesion  is  inflammation  of  the  pulp.  When  this 
inflammation  extends  through  the  foramen  of  the  tooth,  it  involves, 
by  continuity  of  relationship,  the  enveloping  membrane.  As  a  first 
indication  of  such  extension  of  the  trouble,  a  slight  soreness  on  the 
occlusion  of  the  teeth  is  felt,  or  when  the  affected  one  is  struck.  A 
few  hours  later  and  this  soreness  has  increased  to  a  marked  extent. 
The  tooth  is  now  elongated  in  its  socket,  or  thrust  outward,  the  re- 
suit  of  the  congestion.  So  decided  is  this  elongation  that  the  teeth 
cannot  be  brought  properly  together.  Pain  is  heavy,  but  intense, 
the  whole  jaw  sympathizing.  If  the  case  is  allowed  to  run  its 
course,  the  acute  condition  will  continue  from  three  to  six  days, 
terminating,  most  likely,  in  suppuration.  Pus  will  collect  at  the 
apex  and  about  the  root  or  roots  of  the  tooth.  Finally,  after  almost 
unbearable  agony,  it  will  induce,  by  the  pressure  from  its  presence, 
absorption  of  the  confining  bone.  The  pus  will  now  escape  into  the 
soft  parts,  and,  after  provoking  absorption  here,  will  discharge  itself 
as  a  parulis,  or  gum-boil,  and  thus  will  end  for  the  time  the  trouble. 

Treatment  by  resolution  is  always  in  these  cases  to  be  attempted. 
The  inflamed  pulp  should  receive  an  immediate  attention ;  or,  if  it 
be  dead,  it  should  be  syringed  from  its  cavity.  Periodontitis  is  not 
unfrequently  provoked  by  the  presence  of  a  dead  pulp  in  a  closed 
cavity.  In  these  cases,  the  very  first  indication  is  the  opening  of 
such  cavity.  This  very  frequently  Avill  of  itself  yield  a  cure.  Con- 
tinued treatment  consists,  as  suggested,  in  free  scarification  of  the 
gum,  and,  after  such  depletion,  the  application  of  astringents.  Leeches 
to  the  part  act  sometimes  very  happily.  Hot  foot  baths,  saline 
cathartics,  and  counter-irritants  are  also  beneficial.  Rest  to  the  part  is 
to  be  secured  by  heating  a  small  piece  of  gutta-percha,  and  moulding 
it  in  the  form  of  a  cap  over  certain  of  the  healthy  teeth.  A  mouth- 
ful of  cold  water  at  once  hardens  this,  and  thus  occlusion  of  the 
sound  with  the  diseased  tooth  is  prevented. 

If  matter  forms,  absorption  of  the  bone  and  soft  parts  is  to  be 
anticipated  by  drilling,  with  a  spear-shaped  instrument,  into  the 
socket  of  the  tooth.  By  this  little  operation  days  of  suffering  may 
frequently  be  saved. 

Where,  in  ordinary  cases,  it  is  seen  that  resolutions  cannot  be 


DISEASES    OF   THE    TEETH.  209 

effected,  and  a  patient  will  not  submit  to  the  operation  of  opening 
into  the  socket,  abscess  may  be  hastened  by  heat-retaining  applica- 
tions made  directly  to  the  part ;  of  such  applications  there  is  nothing 
better  perhaps  than  a  split  fig,  roasted ;  warm  fluids  may  be  held  in 
the  mouth,  etc.  The  treatment  is  to  be  conducted  on  general  princi- 
ples. Fever  may  be  treated  with  the  ordinary  neutral  mixture.  A 
very  good  general  febrifuge  is  that  prescribed  on  a  former  page: 

R. — Liq.  potassae  citrat.  §iij  ; 
Spts.  seth.  nit.  ^ss  ; 
Ant.  et  potass,  tart.  gr.  i ; 
Morphia  acet.  gr.  ij.     M. 
Sig.  Take  in  dessertspoonful-doses,  pro  re  nata. 

Periodontitis  running  into  abscess  is  most  apt  to  become  chronic. 
A  proper  treatment  is  the  daily  injection  of  the  sinus  with  some  stimu- 
lant, than  which  there  is  nothing  better  than  the  tinct.  of  iodine,  in 
varying  strength,  to  suit  the  conditions.  A  very  happy  treatment  in 
bad  cases  consists  in  keeping  a  tent  stuffed  into  the  tract,  medicated 
with  two  parts  of  iodine  and  one  part  creasote.  Constitutional 
tonic  treatment  is  also  commonly  indicated.  In  my  own  practice  I 
ordinarily  direct  a  daily  salt-bath,  and  fifteen  drops,  three  or  four 
times  a  day,  of  the  following  combination : 

B. — Tinct.  ferri  chl.  5iij  ; 

Quinise  sulph.  gr.  xxv.     M. 

The  ferrated  elixir  of  cinchona  is  another  very  admirable  prepara- 
tion. It  may  be,  however,  that  a  patient  does  not  require  iron.  In 
such  cases  the  quinia  alone,  or  its  equivalent  of  the  bark,  may  be 
prescribed.  (See  chapter  on  Alveolar  Abscess.) 

4th.  Confinement  of  Pus  and  Gas  in  the  Pulp  Cavity. — When 
the  dental  pulp  dies,  decomposition  follows.  As  the  result  of  such 
lesion  we  have  two  sequences:  either  the  decomposed  matter  is 
gradually  absorbed  into  the  dentinal  tubuli,  and  thus  gotten  clear  of, 
as  exhibited  in  the  opacity  of  the  tooth,  or  otherwise  it  becomes  a 
source  of  great  irritation  and  offense  to  the  surrounding  healthy 
structures.  Periodontitis  is  very  apt  to  be  provoked,  the  evolution 
of  gases  forcing  the  matter  unduly  into,  and  in  many  cases  entirely 
through  the  foramen.  If  inflammation  of  the  alveolo-dental  mem- 
brane does  not  result,  then  the  trouble  induced  becomes  of  the  ordi- 
nary neuralgic  character.  The  living  nerve  filament  at  the  foramen, 
still  more  or  less  associated  with  its  continuation  ramifying  in  the 

14 


210  ORAL   DISEASES  AND   SURGERY. 

dead  pulp,  takes  on  inflammation,  and  thus  irritability  not  only  of  this 
special  filament  results,  but  the  whole  trifacial  tract  is  apt  to  sympa- 
thize. Some  of  the  most  severe  and  unbearable  neuralgias  I  have 
ever  treated,  situated  about  the  various  parts  of  the  head,  have  been 
quickly  cured  by  discovering,  and  treating  the  cause  in  a  confined 
dead  pulj).  I  just  now  recall  a  marked  example,— a  patient  of  the  late 
Dr.  Elisha  Townsend,  treated  by  me  for  that  gentleman  during  the 
sickness  which  destroyed  his  valuable  life.  The  patient  was  a  pro- 
fessional man,  and  completely  lost  to  all  self-control,  or  reason,  for 
a  period  of  three  days,  from  the  effect  of  neuralgic  pain  running 
between  the  orl)it  and  the  dura  mater  of  the  anterior  portion  of  the 
cranial  cavity.  In  this  case  not  the  slightest  complaint  was  made  of 
any  of  the  teeth.  Examining  the  mouth,  however,  in  the  search  for  a 
cause,  I  discovered  a  half  carious,  and  evidently  dead  lower  bicuspid 
tooth,  but  with  no  connection  between  the  cavity  of  decay  and  the 
pulp  cavity.  With  a  spear-shaped  drill  I  effected  this  communica- 
tion, and  in  a  single  instant  the  patient  expressed  himself  as  cured. 
Relieved  of  the  pain,  he  fell  into  a  sound  sleep,  which  continued 
some  fifteen  hours  ;  the  next  morning  he  went  about  his  duties  as 
usual. 

Any  and  every  portion  of  the  head  and  throat,  supplied  by  the 
fifth  nerve,  or,  indeed,  by  its  associate  relations,  may  be  the  seat  of 
reflex  trouble  from  a  dead  nerve.  Thus  we  may  have  odonto-gas- 
tralgia,  odonto-cephalalgia,  odonto-cardialgia,  etc. — even  sciatica  has 
been  cured  by  the  extraction  of  a  diseased  tooth. 

The  common  treatment  of  all  such  cases  is  to  remove  the  tooth, 
or  otherwise  drill  an  opening  into  the  pulp  cavity.  The  relief  ex- 
perienced is  generally  almost  instantaneous. 

A  tooth  containing  a  dead  pulp  is  distinguished  by  its  loss  of 
translucency  when  compared  with  its  fellows,  or  in  its  opacity,  ex- 
hibited by  reflecting,  through  the  means  of  a  hand-mirror,  the  rays 
of  the  sun  upon  it. 

5th.  Granules  of  Odeo-denline  in  the  Pulp. — In  rare  cases  there 
is  found  to  exist  an  irritability  of  the  dental  pulp  which  exhausts 
itself  in  the  formation  of  isolated  granules  of  semi-bonelike  char- 
acter, which  obtain  lodgment  in  some  portion  or  other  of  the  organ, 
and  become,  in  turn,  the  source  of  great  offense  to  the  parts,  re- 
sulting indeed  frequently  in  an  odontalgia  than  which  there  are  few 
severer  forms.  To  diagnose  this  condition  is  an  exceedingly  diffi- 
cult matter,  and  it  can,  perhaps,  be  best  done  by  exclusion.  The 
teeth  in  these  cases  present  every  appearance  of  the  highest  health  ; 


DISEASES   OF   THE    TEETH.  211 

no  discoloration,  no  soreness  on  pressure,  and  not  unfrequently  are 
without  the  slightest  local  pain ;  this  manifestation  being  situated 
in  some  distant  part,  as  the  ear,  the  eye,  the  scalp,  etc.  Whether, 
however,  the  pain  may  be  localized  or  dififused,  it  is  always  ex- 
pressed by  the  patient  as  being  entirely  unbearable,  and  is  commonly 
more  or  less  paroxysmal  in  character,  thus  being  mistaken  for  idio- 
pathic neuralgia,  and  frequently  so  treated.  A  case  illustrative  just 
comes  to  ray  mind.  During  a  late  session  of  the  University  of  Penn- 
sylvania, a  student  in  the  medical  department  applied  to  me,  suf- 
fering from  neuralgia,  so  severe  as  to  have  entirely  incapacitated 
him  for  study  for  a  period  of  some  three  weeks.  During  this  time 
he  had  tried  all  the  ordinary  remedies  which  had  suggested  them- 
selves, without  finding  the  slightest  relief  The  pain  varied  between 
the  tuberosity  of  the  superior  maxilla  and  the  ear.  The  teeth,  about 
the  tuberosity,  were  as  sound  and  as  healthy  looking  as  any  I  have 
ever  seen ;  there  was  apparently  no  local  lesion,  while,  on  the  other 
hand,  the  physique  of  the  gentleman  was  not  at  all  of  the  neuralgic 
type.  I  was  perfectly  at  sea  with  the  case,  until,  after  a  day  or  two, 
there  came  to  my  mind  an  instance  of  innodular  calcification  of  the 
dental  pulp  I  had  once  seen,  where  the  patient  had  suffered  in  about 
a  like  manner.  Now  I  was  not  prepared  positively  to  affirm  that 
here  was  a  second  case  of  calcification  ;  but  so  well  satisfied  was  I  of 
the  existence  of  such  a  condition  that  I  requested  and  obtained  the 
consent  of  the  gentleman  to  be  allowed  to  pass  an  exploratory  drill 
into  the  pulp  cavity  of  the  wisdom  tooth.  The  result  was  the  find- 
ing of  the  pulp  filled  with  osseous  granules — granules  of  osteo-den- 
tine,  as  they  are  technically  termed.  The  extraction  of  the  tooth 
was  followed  by  the  immediate  cessation  of  all  pain,  and  the  pa- 
tient was  able  to  go  from  my  office  direct  to  lectures. 

A  marked  case,  where  the  lesion  gives  direct  local  manifestation, 
the  pain  being  seated  directly  in  the  affected  tooth,  exists  in  the  per- 
son of  a  professional  friend.  The  gentleman  may  be  said  to  be 
affected  with  a  diathesis  in  this  direction.  More  beautiful  teeth 
than  he  possesses,  or,  rather,  did  possess,  I  have  never  seen  ;  and 
yet,  one  by  one,  they  take  on  this  condition,  exciting  such  madden- 
ing pain  that,  regardless  of  everything,  he  flies  to  extraction  for 
relief  In  this  way,  within  the  past  few  years,  he  has  lost  all  his 
upper  teeth. 

The  treatment  of  this  form  of  odontalgia  consists  in  drilling  into 
the  body  of  the  affected  tooth,  and  securing  thus  a  cavity  of  reten- 
tion ;  apply  the  arsenious  paste  as  directed.     There  are,  however, 


212  ORAL  DISEASES  AND  SURGERY. 

cases  in  which,  under  these  circumstances,  it  seems  impossible  to 
effect  the  destruction  of  the  organ.  Here  there  is  nothing  to  be 
done  but  to  extract  the  tooth  or  teeth. 

6th.  Sympathy. — Sympathetic  toothache  is  most  frequently  found 
to  be  associated  with  teeth  having  a  common  period  of  eruption. 
Thus,  if  attention  is  called  to  an  aching  bicuspid,  and  examination 
discovers  it  to  be  in  healthy  condition,  we  will  commonly  find  the 
primary  lesion  in  either  of  the  three  fellow-teeth.  If  it  is  the  first 
or  third  molar,  or  any  particular  tooth,  that  may  be  aching,  the  real 
seat  of  pain  may  be  found  in  the  associate  organs.  This  is  the  first 
and  most  common  relation  of  sympathy.  Other  and  indirect  causes 
exist  in  various  directions,  the  most  constant  of  such  associations 
being,  first,  with  the  ear,  second,  with  the  uterus.    (See  Neuralgia.) 

7th.  Recession  and  Absorption  of  the  Gtim  and  Alveolus. — When, 
for  any  reason,  the  gum  falls  below  the  enamel  cap,  the  periosteum 
and  cementum  of  the  tooth  becomes  exposed  to  the  various  sources 
of  irritation.  The  odontalgia  thus  provoked  is  seldom,  however, 
acute  or  severe  in  its  character,  but  dull  and  annoying.  The  practice 
in  these  cases  is  generally  most  unsatisfactory,  resulting,  sooner  or 
later,  in  the  necessity  for  extraction.  If  the  recession  is  associated 
with  acute  conditions,  treatment  directed  to  meet  the  indications  may 
result  very  well ;  but  commonly  such  recession  is  slow  and  chronic, 
and  admits  of  no  remedy.  Medicaments  to  neutralize  or  correct 
irritative  conditions  in  the  oral  fluid  sometimes  are  demanded,  and 
answer  a  very  good  end.  Of  such  neutralizing  agents,  acids  or  ant- 
acids are  employed,  according  to  the  indications  yielded  to  the  test 
by  litmus  paper.  I  myself  generally  use  lime-water  in  the  one 
direction,  or  very  dilute  citric  acid  in  the  other. 


CHAPTER    XL 

DISEASES     OF     THE     TEETH. 

SALIVAEY  CALCULUS. 

Salivary  Calculus  or  tartar  is  that  limelike  material  so  often 
seen  collected  about  the  necks  of  the  teeth.  Observation  elicits  the 
fact  that  the  primary  seat  of  deposit  is  about  the  posterior  or  lingual 
faces  of  the  inferior  central  teeth  and  the  buccal  aspect  of  the  supe- 
rior molars ;  as  in  these  situations  exist  the  outlets  of  the  salivary- 
secretions,  the  inference  is  made  for  us  that  from  such  secretions 
comes,  in  part  at  least,  the  deposit. 

Analysis  of  Saliva.  Analysis  of  Salivary  Calculus. 

Water.  Carbonate  of  lime. 

Ptyalin.  Phosphate  of  lime. 

Fat.  Fat. 

Chloride  of  sodium.  Mucus. 

Chloride  of  potassium.  Accidental  matter. 
Phosphate  of  lime. 
Sulph-cyanide  of  potassium. 

When  the  salivary  secretions  are  sluggish,  the  inorganic  material, 
not  being  held  in  solution  until  fairly  ejected  into  the  mouth,  becomes 
deposited  about  the  roughened  and  inviting  surfaces  of  immediately 
neighboring  teeth.  A  nucleus  once  fairly  formed,  the  secretion  goes 
on  until  serious  secondary  lesions  are  apt  to  result. 

The  first  and  most  marked  effect  of  salivary  calculus  is  upon  the 
teeth  ;  beginning  upon  one  face,  it  soon  involves  the  whole  tooth, 
and,  if  undisturbed,  envelops,  sooner  or  later,  in  an  imperfect 
sheath,  the  whole  denture.  A  mouth  so  filled  with  tartar  is  not  only 
one  of  the  most  disgusting,  but,  as  well,  one  of  the  most  unhealthy 
conditions  presented  in  that  cavity.  Salivary  calculus  soon  destroys 
the  integrity  of  the  teeth.  It  does  this  by  its  eff'ects  on  the  secretory 
crypts  about  their  necks  and  by  compelling  the  diminution  of  the 
periosteal  supply ;  this  membrane  dying  little  by  little  as  the  foreign 
body  encroaches  on  it.    As  a  result  of  such  abstraction  of  nutrition, 

(213) 


214  ORAL   DISEASES  AND   SURGERY. 

the  tooth  soon  dies,  and  is  exfoliated  as  any  other  sequestrum  ;  tooth 
after  tooth  dies,  and  each  week  or  each  month  one  or  more  drops 

from  its  socket. 

Not  unfreqnently  there  may  be  seen  standing,  isolated  and  alone, 
on  some  portion  of  the  dental  arch,  most  frequently,  however,  either 
on  the  anterior  portion  of  the  inferior  arch,  or  the  posterior  portion 
of  the  superior,  a  yellowish-looking  tumor,  which  might  not  in- 
aptly he  compared  to  a  shellbark,  covered  with  inspissated  mucus. 
Sometimes  this  tumor  will  be  found  quite  firm  in  its  position,  seem- 
ing, indeed,  as  if  it  might  have  sprung  from  the  socket  of  some  long 
ago  extracted  tooth  ;  at  other  times  you  will  be  able  to  move  it  quite 
freely,  as  if  it  had  a  fleshy  peduncle.  These  tumors  give  to  the 
patient  a  most  disgusting  appearance,  are  insufferably  oifeusive,  and 
so  detrimental  to  health  that  five  or  six  grains  of  their  substance, 
given  to  a  small  animal,  will  not  unfreqnently  cause  its  death.  The 
comi)osition  of  such  tumors  consists  of  phosphate  and  carbonate  of 
lime,  epithelial  scales,  inspissated  mucus,  and  the  various  debris  of 
a  cavity  devoted  to  mastication.  In  other  words,  they  are  salivary 
calculi.  The  nucleus  of  such  a  growth  is  of  course  a  tooth.  The 
manner  of  formation  is  too  evident  to  need  description.  I  have  re- 
moved these  calculi,  where  the  nucleus  had  become  so  encysted, 
from  crown  to  apex,  that  no  trace  of  it  was  to  be  discovered  without 
dividing  the  mass.  Where,  however,  the  encystment  has  advanced 
to  this  extent,  the  tumor  is  about  ready  to  drop  from  the  mouth  of 
its  own  accord. 

I  have  seen  a  calculus  of  this  kind  encyst  the  six  lower  front 
teeth,  making  as  strange  a  looking  tumor  as  could  be  well  im- 
agined. 

Similar  calculi  develop,  as  may  be  inferred,  in  other  parts  of  the 
mouth.  Thus,  just  within  the  orifice  of  the  duct  of  Steno  they  may 
occasionally  be  found ;  the  tumor,  in  such  a  case,  bulging  out  from 
the  cheek  against  the  second  molar  tooth  of  the  upper  jaw.  The 
formation  of  such  tumors,  in  these  situations,  does  not  necessarily 
imply  the  closure  of  the  orifice  of  the  duct:  they  form  when  the 
gland  is  sluggish;  the  secretion  not  being  in  sufiicient  abundance  to 
hold  the  lime  of  the  saliva  in  solution  until  it  is  ejected  from  the 
duct,  it  falls  on  the  floor  of  the  duct,  and,  lodging,  makes  the 
nucleus. 

I  remember,  on  one  occasion,  to  have  been  called  by  a  fellow- 
practitioner  to  see  a  case  where  a  mass  of  this  calcareous  matter, 
quite  the  size  of  the  largest  almond,  seemed  to  be  growing  from  all 


DISEASES   OF   THE   TEETH.  215 

that  portion  of  the  sublingual  region  anterior  to  the  gland  of  that 
name  ;  one-half  the  tumor  looked  as  if  it  might  be  below  the  level  of 
the  floor  of  the  mouth,  the  mucous  membrane  enveloping  the  mass 
with  ragged  and  ulcerated  edges.  It  certainly  presented  a  very 
strange  and  threatening  look.  My  friend  was  deceived  as  to  its  char- 
acter, because  there  was  no  apparent  direct  association  between  the 
tumor  and  the  neighboring  teeth  ;  and  because  it  was  as  firmly 
fixed  as  though  it  might  have  been  a  growth  springing  from  neigh- 
boring bone.  Yet  this  was  a  salivary  calculus  and  nothing  else,  the 
only  question  being  as  to  its  cause  and  fixedness. 

Looking  about  the  mouth,  I  perceived  that  the  patient  had  certain 
artificial  teeth  on  the  left  side  of  the  arch ;  these  teeth  were  all  coated 
with  tartar,  and  so  associated  thereby  with  the  natural  teeth  as  to 
be  only  distinguishable  by  that  difference  in  the  translucency  so 
immediately  noticeable  by  any  one  experienced  in  such  direction. 
Knowing  well  that  it  is  a  plan  with  many  dentists  to  secure  such 
teeth  by  passing  a  strong  gold  wire  across  the  mouth,  and  which 
wire  not  unfrcquently  buries  itself  within  the  mucous  membrane, 
thereby  occasionally  quite  concealing  it,  I  inferred  at  once  that  this 
would  be  found  the  nucleus  of  the  calculus,  and  accordingly  so  di- 
rected an  examination.  This  was  commenced  by  cutting  away  the 
calculus  from  about  the  artificial  teeth,  and,  as  anticipated,  the  band 
was  revealed  ;  next  was  sought  the  concealed  attachment  of  the  op- 
posite side,  and  this  being  discovered  and  exposed,  the  two  ends 
were  forced  from  the  teeth  which  they  clasped,  and  thus  the  artificial 
teeth,  wire,  and  calculus  were  lifted  from  the  mouth  in  a  body. 

The  site  of  the  calculus,  as  may  be  inferred,  presented  a  cup- 
shaped  ulcerated  depression,  and  was  quite  angry-looking. 

The  only  after-treatment  consisted  in  the  use  of  an  astringent 
wash.     The  ulceration  healed  kindly  in  a  very  few  days. 

I  may  suggest  that  the  existence  of  such  calculi  is  not  an  unfre- 
quent  cause  of  dyspeptic  and  other  alimentary  troubles.  I  have 
just  now,  in  my  mind,  the  memory  of  a  case  of  dyspeptic  con- 
sumption very  illustrative. 

In  her  mouth,  the  patient,  a  lady,  had  but  a  single  tooth,  and 
this  for  years  had  been  so  imbedded  in  salivary  calculus  as  much 
more  to  resemble  a  half-rotted  shellbark  than  a  tooth — her  breath 
was  made  insufferable  by  it.  I  removed  the  offensive  mass,  and  the 
recovery  of  the  patient  was  really  magical  in  its  rapidity. 

Such  calculi  are  to  be  removed  in  any  convenient  manner ;  they 
may  be  pulled  away,  broken  away,  or,  when  loose,  may  be  cut  from 


216  ORAL  DISEASES  AND   SURGERY. 

the  fum  ;  tlie  operation  being  entire)}-  a  mechanical  one,  and  of 
course  very  simple. 

I  forget,  however,  in  such  advice,  my  reference  to  calculi  situated 
in  the  duct  of  Steno.  These  are  to  be  removed,  either  by  enlarging 
the  duct  and  crushing  the  stone,  or  otherwise  by  cutting  down  upon 
it  at  the  most  convenient  point.  When  so  cut  upon,  the  wound 
will  not  commonly  require  any  after-attention. 

Mrs.  Boyd,  a  lady,  sixty-nine  years  of  age,  residing  on  Sansom 
Street,  West  Philadelphia,  applied  to  me,  being  directed  by  some 
unknown  professional  friend,  concerning  a  tumor  of  the  mouth,  from 
an  inflamed  condition  of  which  she  was  at  the  time  enduring  much 
suffering. 

Ocular  inspection  revealed  the  following  condition :  a  tumor, 
very  scirrhus-like,  hard,  lobulated,  and  angry-looking,  occupied  all 
that  portion  of  the  floor  of  the  mouth,  to  the  right  of  the  mesial  line ; 
general  inflammation  of  the  whole  oral  cavity,  to  such  extent  as  to 
make  mastication  too  painful  to  be  practiced,  and  to  render  degluti- 
tion very  difficult.  All  the  teeth  in  the  neighborhood  loose,  and 
occupying  irregular  positions,  the  result,  evidently,  of  a  hyperplastic 
condition  of  the  alveolo-dental  membranes.  The  superficial  cervical 
glands,  especially  those  of  the  submaxillary  region,  sympathizing 
to  a  considerable  extent ;  while  the  submaxillary  gland  itself  was 
so  enlarged  as  to  render  it  sufficiently  prominent  to  be  easily  mapped 
out. 

The  patient  seeming  unable  to  talk  of  anything  except  her  pres- 
ent great  pain,  which  she  described  as  cutting,  tearing,  burning.  I 
dismissed  the  case  for  the  day,  after  prescribing  for  her  immediate 
relief,  namely,  the  ordering  of  leeches,  aperients  combined  with 
Dover's  powder,  astringent  local  applications,  etc. 

Two  days  after,  I  again  visited  the  case.  The  general  inflamma- 
tion was  resolving  very  rapidly,  while  the  mental  equilibrium  of  the 
patient  was  quite  restored. 

The  disease  had  been  pronounced  cancer  by  several  gentlemen, 
and  advice  given  that  no  application  of  any  kind  should  be  made  to 
the  tumor  ;  that  the  patient  should  not  even  permit  it  to  be  handled 
for  any  further  examination.  Under  this  impression  as  to  its 
character,  the  lady  had  given  up  all  hope  of  any  permanent  relief, 
and  was  awaiting  the  end  she  expected. 

The  history  of  the  case  is  as  follows  : 

Eighteen  years  before,  while  engaged  in  milking  an  intractable 
cow,  the  patient  received  under  the  chin  a  kick  so  severe  in  char- 


DISEASES   OF   THE    TEETH.  217 

acter  as  to  confine  her  to  bed  for  over  two  weeks.  This  trouble 
gotten  through,  the  parts  soon  recovered  their  natural  tone,  and 
seemed  as  well  as  ever. 

A  little  over  nine  months  had  passed,  however,  before  she  was 
made  conscious  of  occasional  slight  inflammatory  attacks  about  the 
region  of  the  sublingual  gland.  These  attacks  continued  to  grow  in 
frequency  and  extent,  terminating,  to  use  her  own  language,  "  by  a 
something  which  looked  like  a  whitish  worm,  coming  from  some- 
wheres,  into  her  mouth."  This  worm,  she  said,  "  was  always  the 
assurance  to  her  of  immediate  relief" 

The  trouble  continued  to  recur  for  over  a  year,  when  a  tumor 
began  to  develop  in  the  parts.  The  inflammatory  attacks  now  de- 
creased in  number,  but  increased  in  severity — the  patient  noticing 
that  after  each  inflammation  the  size  of  the  original  tumor  was 
augmented. 

So  the  case  ran  on  for  a  period  of  several  years.  It  was  re- 
marked, however,  nearly  ten  years  back,  that  the  tumor  had  ceased 
to  enlarge  from  the  inflammatory  attacks,  having  at  that  time  gained 
the  size  of  a  pullet's  e^g,  and  neither  increasing  nor  decreasing  up 
to  the  time  of  my  examination.  Understand  me  to  refer  to  the 
tumor  in  a  quiescent  state,  for  each  succeeding  inflammation  swelled 
all  the  parts,  tumor  included,  temporarily,  more  than  the  one  which 
had  preceded  it. 

The  patient's  general  health  was  quite  good ;  there  was  no  con- 
stitutional evidence  to  be  perceived  of  the  cancerous  cachexia. 

Kow,  while  the  history  of  this  tumor,  in  its  local  features,  was  in 
many  points  the  history  of  cancer,  yet,  considering  its  location,  con- 
sidering the  affection  of  the  gland  duct,  which,  as  indicated  by  the 
story  of  the  worm,  evidently  had  association  with  the  tumor  ;  con- 
sidering the  inflammatory  attacks  to  which  the  parts  had  been  so 
frequently  subjected,  and  which  had  resolved  harmlessly;  consider- 
ing the  length  of  time  the  tumor  had  existed,  without  passing  or 
apparently  tending  to  pass  to  the  ulcerative  stage ;  considering 
these  features  in  a  diagnostic  point  of  view,  I  decided,  and  felt  firm 
in  the  decision,  that  the  tumor  was  benign,  and  not  a  cancer. 

What  then  was  it  ?  The  trouble  commenced  evidently  with  in- 
spissated ranula.  My  conviction,  founded  on  the  history,  was, 
that  it  was  still  a  ranula.  Not  ranula,  as  derivatively  we  under- 
stand the  meaning  of  that  word,  but  ranula,  as  pathologically  the 
term  has  association  with  the  salivary  ducts.     What  the  contents 


218  ORAL  DISEASES  AND  SURGERY. 

of  such  cyst,  if  cyst  there  was,  might  be,  I  did  not  feel  prepared  to 
decide. 

Acting  on  the  strength  of  this  conclusion,  I  suggested  to  the 
patient  my  impressions,  and  requested  to  be    allowed  to  pass  a 
scalpel  through  the  parts.     This,  however,  met  with  a  most  de-  ^ 
cided  negative,— the  refusal  not  being,  perhaps,  so  very  strange,  | 
considering  the  assurance  that  Mrs.  B.  had  so  often  received,  that 
any  attempt  to  operate  would  be  her  death-warrant. 

Failing  in  several  other  attempts  at  persuasion,  I  became,  at 
length,  annoyed  at  the  obstinacy  of  the  patient,  and  dismissed  the 
case. 

About  a  month  after,  however,  prompted  by  curiosity,  I  called 
again  on  Mrs.  Boyd.  There  was  now  not  the  slightest  evidence  of 
inflammation  about  the  parts.  The  tumor  was  about  the  size  of  a 
pullet's  v^<f,  hard  almost  as  stone,  and  distinctly  divisible  into  three 
lobes.  The  patient  assured  me  that,  with  the  exception  of  an  occa- 
sional sharp  pain,  she  felt  little  or  no  inconvenience. 

At  this  visit,  more  than  ever  satisfied  with  my  diagnosis,  I  re- 
urged  an  operation,  but  which  was  as  decidedly  refused  as  before. 

On  a  Saturday  morning  I  was  again  called  to  see  the  patient. 
She  was  suffering  from  another  of  the  inflammatory  attacks :  the 
most  severe  she  had  ever  experienced. 

Examination  discovered  the  tumor  swollen  to  such  an  extent  as 
to  throw  the  tongue  over  into  the  left  cheek.  Mastication  had  been 
impossible  for  three  or  four  days,  while  the  ability  to  swallow  was 
being  very  rapidly  lost ;  yet  with  all  this  inflammation,  there  seemed 
no  tendency  to  the  formation  of  abscess. 

Placing  the  old  lady  in  an  arm-chair,  before  the  window,  with- 
out asking  permission  or  offering  any  suggestion,  I  managed  to  get 
the  mouth  under  my  control,  and,  before  she  was  aware  of  the  in- 
tention, I  passed  a  bistoury  directly  through  the  body  of  the  tumor 
— the  knife  grated  over  some  hard  substance. 

After  a  time  spent  in  making  peace,  in  which  I  was  greatly  as- 
sisted by  the  assurance  I  was  enabled  to  give  of  the  dicovery  which 
would  result  in  her  immediate  cure,  I  proceeded  to  the  dissecting 
out  of  the  foreign  body.  This,  as  anticipated,  proved  to  be  a  salivary 
calculus.  The  specimen  is  now  in  possession  of  my  friend.  Dr.  D.  H. 
Agnew,  to  whom  I  presented  it  for  the  pathological  museum  of  the 
Philadelphia  Hospital,  and  is,  perhaps,  one  of  the  largest  on 
record. 

The  pathology  of  such  a  lesion  is  at  once  appreciated,  the  forma- 


DISEASES   OF   THE    TEETH. 


219 


tion  of  the  calculus  in  this  region  was  merely  secondary  to  the  occlu- 
sion of  the  mouth  of  a  gland  duct. 

Dr.  J.  J.  Woodward,  who  made  an  analysis  of  a  portion  of  the 
calculus,  informed  me  that  he  found  it  composed  almost  exclusively 
of  the  phosphate  of  lime,  only  a  very  small  trace  of  the  carbonate 
being  perceptible. 

Saw  Mrs.  Boyd,  for  the  last  time,  one  month  later.  All  induration 
had  so  completely  disappeared  that  I  think  it  would  be  difficult  for 
any  one  who  had  not  seen  the  case  to  say  which  side  of  the  mouth 
the  tumor  had  been  removed  from ;  not  the  slightest  perceptible 
tendency  to  ranula  being  visible. 

The  treatment  of  the  ordinary  collections  of  tartar  is  very  simple, 
and  may  be  made  very  effectual.  Various  cutting  and  scraping  in- 
struments, very  well  understood  by  glancing  at  the  engravings,  are 
used  in  the  process  of  removal.  The  operation  consists  simply  in 
scraping  away  the  mass,  being  careful  not  to  scratch  the  enamel, 
and  afterward  polishing  the  teeth  ;  using  for  the  purpose,  first,  pul- 
verized pumice,  afterward  an  ordinary  burnishing  instrument. 


Fig.  40. — Instruments  employed  in  removing  Tartar  from  Teeth. 


To  prevent  re-collection,  the  action  of  the  glands  is  to  be  increased, 
either  by  local  or  constitutional  sialagogues,  as  seems  indicated.  Or 
if  the  practitioner  doubts,  in  any  individual  case,  the  advisability  of 
such  prescriptions,  then  pumice-stone,  finely  pulverized,  may  be  used 
with  a  good  stiff  brush  ;  or,  what  I  think  will  be  found  a  still  better 
plan,  the  patient  may,  each  few  days,  standing  before  a  mirror,  use 
the  pumice  on  a  piece  of  soft  pine  or  orange  stick. 


220  OFAL  DISEASES  AND   SURGERY. 

Salivary  calculus  has  been  thought  to  produce  caries  and  necrosis 
of  the  alveolar  processes.  I  do  not,  however,  remember  in  my  own 
practice  ever  to  have  seen  such  a  result.  As  the  teeth  drop  out  the 
calculus  falls  away  with  them,  and  thus  its  power  for  evil  ends.  A 
sponfry  and  scorbutic  character  of  gum  tissue,  and  consequent  hem- 
orrhage, are  very  common  associations;  but  the  practitioner  at  once 
sees  that  the  cure  is  in  bis  own  hands. 


CHAPTER   XI I. 

DISEASES   OF   THE   TEETH. 

DENUDATION. 

This  affection,  at  once  appreciated  by  referring  to  the  drawings, 
is,  without  doubt,  one  of  the  most  deforming  conditions  to  which  the 
dental  organs  are  subject.  It  is  sometimes  seen  attacking  every  in- 
dividual tooth,  at  others,  confining  its  ravages  to  a  very  few.  A 
very  common  seat  of  the  affection  is  where  the  gum  festoons.  Here 
may  be  seen  a  sulcus  or  groove  passing  from  tooth  to  tooth,  involv- 
ing all  those  situated  in  the  anterior  part  of  the  arch.  Another 
form  of  the  affection  involves  the  cutting  edges  alone,  while  in  still 
other  cases  the  depressions  are  situated  promiscuously  over  every 
portion  of  the  teeth. 

The  disease,  commencing  as  a  slight  gutter  or  break  in  the 
enamel,  progresses  with  a  varying  degree  of  rapidity,  sometimes 

Figs.  41  and  42. — Denudation. 


moving  with  such  slow  pace  as  scarcely  to  be  observed  from 
year  to  year;  in  other  instances,  and  these,  unfortunately,  much 
the  most  frequent,  making  constant  attention  necessary  to  the  pre- 
servation of  the  organs.  Occasionally  the  process  begins  at  a  num- 
ber of  points,  and  these  enlarging,  finally  coalesce,  to  the  destruction 
not  unfrequently  of  all  the  anterior  enamel  wall. 

Concerning  the  cause  or  causes  inducing  this  condition  much 
diversity  of  opinion  exists.  My  own  conviction  is  that  it  is  mark- 
edly a  disease  of  predisposition,  the  result  of  impressions  made  on 
the  enamel  at  the  period  of  its  formation,  and  which  predisposition 
has  never  by  accident  or  design  been  corrected.  Why  some  of  these 
teeth  should  denude  rapidly  and  others  slowly  must  depend  on  both 
intrinsic  and  extrinsic  circumstances.      That  these  circumstances, 

(221) 


ooo  ORAL  DISEASES  AND  SURGERY. 

however,  arc  not  appreciated  from  that  practical  stand-point  which  i 
should  enable  us  to  use  them  for  the  benefit  of  the  patient,  is  un-  I 
fortunatolv  too  true.  Except  as  a  mechanical  treatment  is  concerned  i 
we  can  only  look  on,  and  trust  for  a  speedy  and  limited  line  of  de-  { 
markation.  I  am  in  the  habit,  however,  of  prescribing  freely  of  the  1 
lime  tonics ;  but  whether  such  treatment  does  any  good  I  do  not 
feel  myself  able  to  say. 

Another  source  of  dental  trouble  in  this  direction  arises  from  spon-  | 
taneous  or  mechanical  abrasion  of  the  cutting  edges  of  the  teeth.  ' 
Spontaneous  abrasion  is  a  most  infrequent  aflfection,  and  where  not  \ 
traceable  to  mechanical  action  is  too  obscure  to  permit  the  venturing 
of  an  opinion.     The  supposition  that  the  parts  are  chemically  de- 
stroyed by  the  secretion  of  an  acid  secreting  gland,  which  it  is  claimed 
has  been  discovered  in  the  apex  of  the  tongue,  is  akin  to  many  simi- 
lar suppositions. 

Abrasion  of  the  teeth  from  mechanical  causes  is  a  very  common 
affection,  and  a  very  unfortunate  one.  The  articulation  of  the  two 
dentures  has  much  to  do  with  the  production  of  such  a  condition ; 
indeed,  everything,  if  w^e  would  except  an  abnormal  softness  of  enamel 
as  found  in  certain  teeth.  Teeth  that  articulate  scissor-fashion,  the 
one  set  over  or  in  front  of  the  other,  seldom  suffer  from  this  trouble. 
It  is  most  markedly  an  affliction  of  direct  articulation. 

Per.sons  having  jaws  thus  articulated  find  their  teeth  year  by 
year  wearing  shorter ;  and  was  it  not  that,  as  this  abrasion  goes  on, 
nature  offsets  the  waste  by  internal  repairs,  throwing  out  layer  after 
layer  of  osteo-dentine,  the  dental  pulps  would  be  quickly  enough 
exposed. 

The  character  of  food  used,  w^hile  perhaps  it  would  never  yield 
this  condition,  yet  the  predisposition  in  the  articulation  existing, 
without  doubt  assists  in  the  destruction.  Thus  it  is  remarked,  that 
sailors  eating  constantly  of  hard  bread,  and  chewers  of  tobacco,  are 
most  subject  to  abrasions ;  but  this  is  only  true  strictly  as  it  applies 
to  such  as  have  this  peculiarity  of  articulation,  and  wnth  such  the 
progress  of  the  abrasion  is  very  rapid. 

A  means  of  relief,  which,  wiiile  fairly  successful,  is  associated 
with  much  discomfort,  consists  in  the  adaptation  to  the  posterior 
teeth  of  caps  of  metal ;  these  caps  take  the  strain  off  mastication, 
and  thus  protect  the  teeth.  Another  mode,  but  which  is  apt  to 
excite  odontitis,  consists  in  cutting  out  cavities  from  the  abrading 
faces  of  the  teeth,  and  supplying  the  place  of  the  removed  dentine 
with  plugs  of  gold.  This  latter  plan  has  many  advocates,  and  is 
highly  commended  by  practitioners  of  experience  and  judgment. 


CHAPTER    XII  I. 


THE    EXTRACTION   OF   TEETH. 


The  extraction  of  a  tooth  is  an  easy  or  difficult  matter,  according 
as  the  principles  involved  in  the  operation  are  clearly  or  obscurely 
comprehended.  In  the  adult  mouth  there  are  thirty-two  teeth,  and 
these,  as  the  study  of  their  extraction  is  concerned,  are  compre- 
hended under  six  classes. 

Fig.  4o. — Diagram  of  Teeth. 


Fig. 

44. 

Q 

1 

PI 

n 

P 

^B( 

111 

iffl 

[   M 

H^_/J|^H 

■Hirlj 

Bfi'  ""i^H 

If  ■ 

■    Jfl 

H'  |H 

■  F M 

Bk\  1  ''^H 

III 

H  1^1 

■i  JH 

1  iMj . 

^Ki 

H^\a^^^| 

n 

\  Im 

w 

IB 

Iw 

bI 

i'lg.  4ii,  permanent  teeth  of  upper  jaw.    Fig.  44,  of  lower  jaw.     1,  2,  incisors;   3,  canine; 
4,  5,  bicuspids  or  small  molars  ;  6,  7,  8,  largo  molars  or  grinders. 

The  first  of  these  classes  embraces  the  eight  central  and  lateral 
incisors;  teeth  with  cone-like  roots,  and  accommodated  in  alveoli 
representing  hollow  cones. 

The  second  class  embraces  the  cuspidati,  and  are  represented  by 
the  partly  flattened  cone. 

(223) 


224  ORAL  DISEASES  AND  SURGERY. 

The  third  class  embraces  the  bicuspidati,  and  are  represented  by 
the  flattpnod  cone. 

The  fourth  class  embraces  the  superior  first  and  second  molars, 
teeth  having  three  roots,  two  external  cone  roots,  situated  antero- 
postoriorly,  with  the  interspaces  looking  toward  the  cheek;  the 
third,  gonerally  a  flattened  root,  looking  toward  the  palatine  arch. 

The  fifth  class  embraces  the  inferior  first  and  second  molars,  teeth 
having  two  roots,  one  looking  anteriorly,  the  other  posteriorly ;  the 
interspace  looking  outward  and  inward. 

The  sixth  class  embraces  the  four  wisdom  teeth.  These  are  single- 
rooted  as  a  rule,  with  a  curve  looking  backward. 

To  extract  a  tooth  of  the  first  class,  the  application  of  the  force  is 
required  in  a  twofold  direction,  rotatory  and  downward,  or  upward, 
as  the  case  may  be. 

To  extract  a  tooth  of  the  second  class,  the  force  is  required  in  a 
threefold  direction,  downward  or  upward,  lateral,  and  rotatory. 

To  extract  a  tooth  of  the  third  class,  upward  or  downward,  and 
lateral,  or  inward  and  outward,  as  one  loosens  a  nail. 

To  extract  a  tooth  of  the  fourth  class,  the  same  application  of  the 
force;  one-half  of  such  a  tooth  is,  however,  to  be  extracted  at  a 
time — that  is,  we  first  break  the  attachment  of  either  the  inner  or 
outer  roots,  and  feeling  these  yield,  the  force  is  instantly  brought  to 
bear  upon  the  other.  In  extracting  4:eeth  of  this  class  in  this  man- 
ner, much  care  is  necessary  in  guarding  against  a  too  great  extent 
of  lateral  motion ;  otherwise  the  roots,  instead  of  yielding,  will  be 
found  to  break,  thus  complicating  matters  very  seriously. 

Teeth  of  the  fifth  class  require  the  lateral  and  direct  application 
of  the  force ;  they  are  to  be  gently  rocked  inward  and  outward  until 
felt  to  yield,  when  they  are  at  once  to  be  lifted  from  their  sockets. 

Teeth  of  the  sixth  class  are  to  be  carried  backward  and  upward, 
or  downward,  in  the  line  of  the  axis  of  their  single  curved  root ; 
such  applications  will  make  easy  an  extraction  which  might  other- 
wise be  attended  with  much  risk. 

INSTRUMENTS. 

Instruments  are  now  made  in  consideration  of  the  anatomical  pe- 
culiarities of  the  teeth  for  which  they  are  intended. 

Figs.  45  and  46  represent  instruments  adapted  to  the  formation  of 
the  incisors,  both  of  the  superior  and  inferior  jaws. 

Fig.  45  represents,  when  closed,  a  hollow  cone,  the  least  circum- 


EXTRACTION   OF   TEETH. 


225 


ference  of  which  is  at  the  free  edge.  Reference  to  the  incisor  teeth 
exhibits  them  as  double  cones,  the  base  abutting  just  external  to  the 
alveolar  process.     This  instrument,  if  thrust  beyond  the  bases  of 

Fig.  45. — Incisor  Forceps  for  Sitertor  Jaw. 


Fig.  46. — Incisor  Forceps  for  Inferior  Jaw. 


the  cones,  is  found  to  have  the  firmest  possible  hold  of  the  tooth, 
and  to  fit  it  perfectly  in  its  various  diameters.  To  apply  it,  if  the 
tooth  is  situated  in  the  superior  jaw,  the  operator  stands  to  the  right 

Fig.  47. — The  Matnarc  Forceps— Eight  and  Left. 


of  his  patient.     If  the  lower  jaw  is  the  seat  of  operation,  I  think  it 
will  be  found  most  convenient  to  seat  the  patient  upon  a  low  chair, 

15 


226  ORAL  DISEASES  AND  SURGERY. 

and  stand  directly  back  of  bim,  using  the  curved  forceps,  and  lean- 
ing over  his  head  to  make  the  extraction. 

The  same  instruments  apply  equally  well  to  teeth  of  the  second 
and  third  classes;  the  straight  forceps  for  the  superior  jaw,  the 
curved  for  the  inferior.     The  applications  imply  the  same  positions. 

Than  the  Maynard  forceps  (Fig.  41)  nothing,  I  think,  could  be  de- 
vised more  happily  meeting  the  anatomical  requirements  of  class  four. 

The  outer  beak,  horn-shaped,  is  designed  to  slip  in  the  interspace 
between  the  two  buccal  roots.  The  inner  beak,  flat  and  grooved, 
fits  accurately  and  firmly  against  the  palatine  fang.  These  forceps 
are,  of  course,  in  pairs,  and  apply,  the  one  to  the  right  side,  the 
other  to  the  left. 

Other  forceps  are  also  in  use  for  the  extraction  of  these  teeth,  and 
it  might  be  desirable  to  have  one  set  at  least  beside  the  Maynard. 

Fio.  48.— The  Ordinary  Molar  Forceps— Right  and  Left. 


To  apply  these  forceps  the  operator  stands  to  the  right  of  his  pa- 
tient, precisely  as  in  the  case  of  teeth  of  the  first  three  classes,  the 
left  arm  passing  around  the  head,  the  fingers  of  the  left  hand  holding 
the  lip  out  of  place.  In  using  the  Maynard  forceps  care  must  be 
taken  to  thrust  the  point  of  the  horn  directly  into  the  interspace, 
otherwise  the  operator  would  have  no  hold  on  the  tooth ;  this  being 
in  position,  the  flat  blade  is  carried  along  the  palatine  fang  as  high 
as  possible.  A  few  rocks  of  the  tooth  inward  and  outward,  com- 
bined with  a  direct  force  in  the  line  of  its  long  axis,  and  it  will  be 
found  to  give  way. 

Fig.  49  represents  a  forceps,  invented  by  the  same  gentleman,  for 
the  extraction  of  class  five.  This  consists  of  two  hornlike  beaks, 
which,  as  is  seen  by  reference  to  class  five,  are  admirably  adapted  to 


EXTRACTION  OF   TEETH. 


227 


the  interspace  looking  outward  and  inward.  To  apply  this  forceps, 
which  is  equally  adapted  to  either  side  of  the  mouth,  the  patient  is 
to  be  seated  upon  a  low  chair,  while  the  operator  stands  behind  and 
leans  forward  over  the  head.  The  gum  being  well  lanced,  the  beaks 
of  the  forceps  are  thrust  down  until  they  are  felt  entering  the  inter- 
spaces, the  exact  center  line  of  the  tooth  corresponding  to  this  space. 

Fig.  49. — Maynarb  Forceps  for  Inferior  Molars. 


So  direct  and  happy  is  the  application  of  force  with  this  instrument 
that  it  is  not  unfrequently  the  case  that  the  simple  closing  of  the 
handles  will  cause  the  tooth  to  start  from  its  socket.  A  few  rocks, 
however,  inward  and  outward,  will  always  easily  effect  the  extrac- 
tion. The  great  advantage  of  the  instrument  over  such  as  are  or- 
dinarily used,  is  markedly  evident  where  a  tooth  is  much  decayed 
about  its  crown ;  the  instrument  lifting  from  beneath  rather  than 
exerting  pressure  upon  the  crown.  These  instruments  of  Dr.  May- 
nard  cannot  be  too  highly  applauded. 

Fig.  50. — The  Phtsick  Forceps. 


Fig.  50  represents  a  forceps,  designed  by  the  late  Dr.  Physick,  for 
the  extraction  of  the  wisdom  teeth.  This  instrument,  as  is  seen,  is 
a  double  inclined  plane,  and,  in  consideration  of  the  necessity  of 
throwing  these  teeth  backward,  is  designed  to  be  applied  between 
the  tooth  to  be  extracted  and  the  one  directly  anterior  to  it.  The 
closure  of  the  handles  is  expected  to  throw  the  tooth  from  its 
socket. 

It  sometimes  occurs,  however,  that  these  teeth,  as  is  seen  in  the 


228  ORAL  DISEASES  AND  SURGERY. 

superior  tooth  in  the  drawing,  have  more  than  a  single  root;  and 
these  roots,  instead  of  being  inclined  in  a  common  axis,  are  fre- 
quently  spread  out  in  various  directions.  In  cases  of  this  kind 
it  is  plain  that  the  instrument  would  not  apply.  Another  objection 
to  its  use  lies  in  the  injury  apt  to  be  inflicted  on  the  anterior  or  ful- 
crum tooth;  this  not  unfrequently  having  the  enamel  so  crushed  and 
broken  as  to  expose  the  more  susceptible  dentine,  and  thus  lead  to 
caries.  Still  another  oVijection  lies  in  the  contusion  inflicted  on  the 
periosteum,  this  membrane  being  occasionally  so  injured  as  to  result 
in  its  severe  inflammation. 

Fig.  51.— Forceps  for  Wisdom  Teeth. 


Fig.  51  is  an  instrument,  a  modification  of  Maynard's  cow-horn, 
employed  by  myself  in  the  extraction  of  this  class  of  teeth,  and 
which  I  find  to  answer  the  end  very  satisfactorily. 

With  this  instrument,  bent,  as  is  seen,  at  nearly  right  angles,  one 
has  little  difficulty  in  getting  at  either  upper  or  lower  teeth,  and  the 
inclination  backward  is  not  at  all  difficult  to  be  given.  Two  pairs, 
right  and  left,  are  required.  The  ordinary  key  instrument,  if  lightly 
and  delicately  made,  answers  a  very  admirable  purpose  with  this 
class.  The  roots  being  generally  quite  short,  there  is  none  of  the 
common  danger  of  alveolar  fracture,  and  being  but  lightly  set  in 
their  sockets,  and  easily  yielding,  the  application  of  but  very  little 
force  is  required. 

In  using  the  key,  the  fulcrum  should  be  placed  on  the  inner  face 
and  well  back  upon  the  tooth,  the  claw  being  upon  the  opposite  face 
and  well  in  front ;  this  application  allows  of  the  proper  direction  of 
the  force,  and  admits  of  the  easy  and  natural  removal  of  the  organ. 

Another  instrument  employed  in  the  extraction  of  these  teeth  is 
the  elevator. 

To  apply  this  instrument,  the  grooved  face  is  laid  against  the 
antero-lateral  aspect  of  the  tooth,  and  being  carried  down  to  the  pro- 
cess, the  hand  is  depressed  so  that  the  free  edge  alone  impinges;  the 
tooth  is  then  pushed  outward  from  its  socket,  and  backward.  When 
wisdom  teeth  are  not  too  firmly  adherent,  this  is  an  admirable  in- 


EXTRACTION  OF   TEETH. 


229 


strumcnt  for  their  removal ;  care,  however,  is  necessary  that  it 
shall  not  slip  from  the  tooth  and  inflict  injury  on  the  neighboring 
soft  parts. 

Fig.  52. — The  Elevator — Yakious  Forms. 


Extraction  of  Fractured  Teeth  and  Roots  of  Teeth. — It  not 
unfrequently  happens  that  in  attempts  to  extract  teeth,  fractures  re- 
sult ;  and  such  fractures  must,  of  course,  present  the  greatest  variety 
of  aspect,  and  require  various  resources  for  the  removal  of  the  parts 
left. 

Teeth  of  the  first,  second,  and  third  classes  present  the  same  com- 
mon features  of  fracture,  and  may  claim  a  first  attention.  Fig.  53 
represents  the  alveolar  line,  and  the  various  relations  held  to  this 
line,  or  free  laorder,  by  fractured  teeth  or  roots. 

A  fractured  tooth,  as  represented  by  Subfig.  1  (the  first  root  to 
the  left),  is  placed  in  no  worse  condition  for  easy  extraction  than 


230  ORAL  DISEASES  AND  SURGERY. 

before  the  occurrence  of  the  accident.     The  same  forceps  and  the 
same  manner  of  its  application  still  apply  to  it. 

Subfi".  2  represents  a  slight  modification  of  the  same  condition. 
The  one  forceps  and  the  one  application  still,  however,  apply.  It 
is  advisable,  if  the  tooth  is  at  all  brittle,  to  work  the  blades  of  the 
instrument  well  beneath  the  alveolus.  This  affords  greater  support 
and  yields  increased  security. 

Fig.  53. — Relation  of  Fractured  Roots  to  Alveolar  Line. 

1.  2.  3.  i.  5.  6.        7. 


Subfig.  3  may  represent  a  bicuspid  tooth  with  the  crown  half 
broken  away.  In  such  a  case,  if  the  remaining  portion  is  not  at  all 
brittle,  and  if  the  process  is  soft  and  spongy,  the  forceps,  as  de- 
scribed, having  well-sharpened  blades,  may  again  be  tried,  working 
them  well  beneath  the  process,  and  securing  all  the  hold  possible  on 
the  root.  If  fracture  again  occurs,  which,  indeed,  is  very  likely, 
simulating  figures  4  and  5,  the  cutting  forceps  is  to  be  employed. 

To  use  a  cutting  forceps,  make,  with  a  scalpel  or  other  blade,  an  J 
incision  on  either  side  of  the  root  through  the  soft  parts  directly 
down  to  the  process;  these  cuts  must  correspond  with  the  exact 
center  line  of  the  root.  The  forceps  is  now  to  be  applied  scissors- 
fashion,  cutting  directly  through  the  bone.  Being  thus  brought  in 
contact  with  the  root,  and  grasping  it  perhaps  full  half  its  length, 
the  removal  is,  of  course,  a  perfectly  simple  matter. 

Some  operators  prefer  to  precede  the  cutting  forceps  with  the 
elevator,  and  this  instrument,  in  many  cases,  certainly  effects  the  end 
very  well. 

In  the  application  of  the  cutting  forceps,  it  not  unfrequently  hap- 
pens that,  from  want  of  care,  the  blades,  instead  of  coming  directly 
upon  the  root,  slip  to  the  back  or  front  of  it.  In  these  cases  the 
fang  may  generally  be  easily  enough  picked  out  with  the  ordinary 
root  forceps.  A  form  of  cutting  forceps  used  by  many,  consisting  of  a 
double  curved  blade,  avoids  this  accident,  but  it  is  to  be  objected 
to  on  account  of  the  wound  it  makes. 

Roots,  represented  in  4,  5,  6,  and  7,  are  removed  on  a  common 


EXTRACTION  OF   TEETH.  231 

principle.  The  first  attempt  is  to  be  made  with  the  elevator :  lay- 
ing the  groove  of  this  instrument  closely  against  the  root,  its 
sharpened  knifelike  edge  is  insinuated  between  the  fang  and  pro- 
cess, being  worked  down  as  far  as  possible.  The  handle  is  now 
carried  obliquely  to  the  line  of  the  root,  and  thus,  with  careful  yet 
oscillatory  motion,  the  piece  is  forced  from  its  bed.  It  is  very  well 
known,  however,  that  with  a  dense,  heavy,  alveolar  process,  this 
instrument  cannot  be  made  to  operate  so  happily,  it  being  next  to 
impossible  to  insinuate  it  between  the  bone  and  tooth.  Under  these 
circumstances,  another  instrument,  the  screw,  may  be  brought  into 
requisition.     See  Fig.  54. 

Fig.  54. — The  Screw. 


The  screw  is  designed  to  operate  upon  the  tooth  root  as  the  spiral 
operates  upon  the  cork.  Well  tempered,  and  very  sharp,  it  is  intro- 
duced into  the  pulp  canal,  and  quietly  and  gently  turned  until  it  has 
taken  a  firm  hold.  A  simple  direct  movement,  and  the  root  is  brought 
away. 

It  may  happen,  however,  that  no  hold  suflSciently  firm  for  the 
extraction  can  be  obtained  with  this  instrument.  When  this  is  the 
case  it  may  be  laid  aside,  and  the  always  reliable  cutting  forceps 
brought  into  requisition.  If  preferred,  however,  the  screw  can  be 
bored  into  the  tooth  until  fracture  is  produced,  and  this  will  some- 
times enable  us  quite  easily  to  pick  away  the  splinters:  particularly 
will  this  be  found  to  be  the  case  when  the  line  of  the  fracture  divides 
the  root  in  its  length. 

Roots  of  the  molar  and  wisdom  teeth,  superior  and  inferior,  are 
removed  on  a  common  principle.  In  the  use  of  the  elevator,  a  very 
happy  result  is  not  unfrequently  secured  by  applying  the  blade  to 
the  inner  face  of  the  root,  carrying  the  shank  across  the  mouth,  and 
making  a  fulcrum  of  some  convenient  opposite  tooth. 

Where  the  roots  of  a  molar  tooth  are  so  firmly  fixed  as  to  seem 
incapable  of  removal  with  the  application  of  an  ordinary  amount  of 
force,  it  is  better  to  divide  them.     This  is  easily  done  with  the 


232  ORAL  DISEASES  AND  SURGERY. 

cutting  forceps,  and,  after  the  separation,  each  root  may  be  picked 
out  sinffly,  and  generally  with  comparative  ease. 

Deformed  or  Anomalous  Teeth.— Understanding  the  principles 
on  which  teeth  of  ordinary  character  are  extracted,  the  practitioner 
needs  little  instruction  so  far  as  anomalies  are  concerned. 

Subfigures  1,  2,  3,  4,  and  5  represent  five  anomalies,  and  they  may 
very  well  stand  for  the  class.  In  removing  such  teeth  from  the 
mouth,  the  matter  of  greatest  importance  is  to  recognize  them.  Now, 
while  this  cannot  in  all  cases  be  done  so  as  to  appreciate  exactly 
the  condition  of  the  roots,  yet  we  can  always  say  that  some  impedi- 
ment to  the  removal  exists ;  and  this,  after  all,  is  the  most  important 
matter,  as  it  influences  us  in  the  amount  of  force  exhibited,  and 


which,  too  freely  rendered,  might  result  in  fracture  of  the  bone,  or 
still  greater  injury  to  surrounding  parts. 

A  tooth,  as  represented  in  Subfig.  1  (the  first  to  the  left),  will 
generally  yield  in  its  roots  so  as  to  pass  the  intermediate  piece  of 
process.  If  it  does  not  so  yield,  then  this  wedge  of  bone  will  frac- 
ture and  be  brought  away.  Such  fracture,  however,  results  in  no 
harm,  and  is  to  be  esteemed  of  little  consequence. 

Subfig.  2,  by  the  great  curve  in  the  root,  is  made  incapable  of 
passage,  unless,  after  being  loosened,  it  is  carried  outward  in  the 
direction  of  the  axis  of  the  curve.  In  this  way  it  is  easily  removed. 
The  character  of  the  curve  is  recognized  by  the  resistance  offered 
when  the  tooth  is  carried  in  certain  positions,  and  the  absence  of  such 
resistance  when  carried  in  the  proper  line.  The  attempt  to  remove 
such  a  tooth  by  simple  force  would  result  either  in  fracture  at  the 
curve,  in  lifting  out  a  neighboring  tooth,  or  in  fracture  more  or  less 
extensive  of  the  alveolar  process. 

Subfig.  3  represents  exostosis  of  a  root.  A  tooth  fang  so  enlarged 
will  not  pass  through  the  process  unless  the  bone  is  very  open  in  its 
structure.  Such  a  tooth  may  be  made  quite  loose,  but  while  it 
moves  freely  enough  in  its  socket,  it  is  felt  to  be  held  by  something 
abnormal.  To  free  such  a  tooth,  it  is  only  necessary  to  use  the 
cutting  forceps,  or,  what  I  prefer,  take  the  ordinary  small  surgical 
chisel,  and  cut  away  sufficient  of  the  process  to  admit  of  the  passage. 


EXTRACTION  OF   TEETH.  233 

This  little  operation  is  easy  of  accomplishment,  and  must  prove 
adequate  to  the  end. 

Subfig.  4  represents  one  form  of  twin  teeth.  The  two  must  be 
extracted  together,  which  may  be  difficult  or  the  reverse,  accord- 
ing to  the  character  of  the  process.  It  is  well,  before  making  the 
effort  to  extract,  to  free  the  process  from  the  teeth  as  thoroughly  as 
possible ;  this  is  done  by  a  sharp  and  flat  elevator  or  the  chisel. 

Subfig.  5  represents  a  second  form  of  twin  growth,  the  result  of 
original  germ  union.  If  the  offshooting  bulb  is  situated  within, 
and  covered  by  the  process,  it  is  to  be  treated  as  if  it  were  a  case  of 
exostosis  of  the  fang.  These  germ  unions  are  exceedingly  rare,  and 
one  might  not  be  met  with  in  a  lifetime. 


CHAPTER    XIV. 

GENERAL   REMARKS   ON   EXTRACTION, 

The  relationship  of  the  teeth  with  the  jaws  is  through  the  medium 
of  a  cellular  process  known  as  the  alveolar.  Each  tooth  has  pits  or 
alveoli  corresponding  to  the  number  and  character  of  its  roots  ;  thus, 
the  central  and  lateral  incisors,  the  cuspidati,  and  the  bicuspidati, 
having  each  but  one  root,  have  each  but  one  alveolus. 

The  molar  teeth  of  the  superior  jaw  have  three  roots,  conse- 
quently a  threefold  relation  to  the  alveolar  process. 

The  molar  teeth  of  the  inferior  jaw  have  two  roots  and  two  al- 
veoli. 

The  wisdom  teeth,  as  a  rule,  have  a  single  short  curved  and 
stumpy  root,  consequently  a  similar  alveolus. 

The  association  of  the  teeth  with  their  alveoli  is  through  the 
medium  of  periosteal  tissue ;  this  membrane  is  coarse  and  fibrous 
about  the  free  edge  of  the  bone,  loose  and  cellular  as  it  gets  deeper. 
A  proper-shaped  lancet  may  be  made  to  excise  the  coarse  fibers ; 
consequently,  the  operation  of  extraction  should  always  be  preceded 
by  that  of  thorough  lancing.  In  this  way  much  of  the  strength  of 
the  relationship  of  the  tooth  with  its  socket  is  to  be  overcome. 

A  tooth  extracts  difficultly  or  easily  as  influenced  by  the  character 
of  its  periodenteum,  and  the  loose  or  firm  character  of  its  alveolus, 

A  limited  fracture  of  the  alveolar  process  is  generally  not  to  be 
considered  a  matter  of  much  consequence.  If  an  extensive  fracture 
should  associate  with  an  extraction,  the  tooth  and  bone  may  be  laid 
carefully  back  in  place,  and  treated  as  any  common  fracture ;  or,  if 
this  does  not  seem  desirable,  the  fractured  piece  may  be  dissected 
from  the  soft  parts,  and  the  wound  treated  on  general  principles. 
Sometimes,  when  too  much  force  is  injudiciously  used,  a  fracture 
may  occur,  including  several  teeth.  In  such  accident,  the  circum- 
stances of  each  peculiar  case  must  direct  the  practitioner ;  they  are 
ugly  and  generally  unnecessary  troubles,  and  not  apt  to  occur  where 
proper  care  is  exercised.  If  I  myself  should  meet  with  such  an  acci- 
dent, I  should  certainly  make  a  first  effort  to  reunite  the  parts ;  failing 
(234) 


GENERAL  REMARKS   ON  EXTRACTION.  235 

in  which,  I  would  have,  of  course,  no  resource  but  to  dissect  away 
the  piece,  or  otherwise  wait  on  nature  for  a  process  of  exfoliation. 

Laceration  of  the  gums  is  an  accident  frequently  associated  with 
the  careless  extraction  of  teeth.  Such  laceration  may  be  trifling  or 
it  may  be  serious,  and  is,  perhaps,  always  to  be  guarded  against  by 
careful  attention  to  lancing.  A  small  piece  of  gum  torn  by  a  tooth 
as  it  comes  away,  had  better  always  be  removed  ;  left  in  the  mouth, 
it  is  a  source  of  annoyance,  and  reflects,  in  the  mind  of  the  patient, 
on  the  practitioner.  Large  strips  are  to  be  carefully  laid  back  in 
place,  and  secured  by  one  or  more  stitches,  or  other  convenient 
means  of  retention. 

Hemorrhage. — Hemorrhage  after  extraction  is  influenced  by  two 
circumstances :  the  state  of  the  parts  and  the  predisposition  of  the 
patient.  An  ordinary  tooth  extraction  is  followed  by  hemorrhage 
lasting  but  a  very  few  minutes.  In  extraction  for  periosteal  trouble 
the  bleeding  is  more  profuse ;  but  such  hemorrhage,  if  at  all  reason- 
able, should  not  be  interfered  with  ;  it  expedites  the  cure  of  the  case 
wonderfully,  relieving  the  general  congestion  of  the  parts. 

In  cases,  however,  where  a  hemorrhagic  diathesis  exists,  alveolar 
hemorrhage  is  not  unfrequently  of  the  most  profuse  character, 
making  necessary  the  most  judicious  and  energetic  treatment  for  its 
arrestation.  Two  cases,  occurring  in  the  persons  of  father  and  son, 
will  illustrate  this  direction  of  practice. 

Mr.  B.,  aged  19,  applied  to  his  dentist  for  the  removal  of  the 
second  superior  molar  of  the  right  side.  The  operation  over,  the 
bleeding  seemed  not  excessive,  and  the  patient  was  dismissed  as 
usual.  On  the  same  day,  in  the  latter  part  of  the  afternoon,  bleed- 
ing recommenced  ;  Monsel's  solution  of  the  persulphate  of  iron  was 
employed,  and  the  patient  again  dismissed.  During  the  night  hem- 
orrhage again  recurred,  and  the  family  physician  was  sent  for  ;  the 
solution  of  iron  was  again  employed,  and  a  temporary  arrest  again 
secured.  The  next  day  it  reappeared,  and  nitrate  of  silver  was 
applied  in  the  alveolus.  This  controlled  the  hemorrhage  until 
the  succeeding  day,  when  it  again  appeared ;  and  so  off  and  on  over 
a  period  of  eight  days.  At  this  time  I  first  saw  the  case  in  consulta- 
tion, the  patient  being  unable  to  swallow  any  other  than  liquid  food, 
owing  to  the  swelling  of  the  fauces  and  oesophagus  from  the  effects 
of  the  nitrate  of  silver. 

In  now  treating  the  case  we  first  took  from  the  cavity  the  half- 
coagulated  clot  it  contained,  and,  washing  the  parts  thoroughly,  dis- 
covered that  the  bleeding  came  not  alone  from  the  socket  of  the  tooth, 


236  ORAL  DISEASES  AND  SURGERY. 

but  from  about  the  margins  which  had  been  ulcerated  by  the  various 
applications.  The  next  step  was  to  secure  an  impression  of  the  roof 
of  the  mouth,  which  was  obtained  without  difficulty  through  the 
employment  of  the  common  impression  wax  and  cup.  To  this  impres- 
sion a  silver  plate  was  struck.  The  cavity  was  now  carefully  packed 
with  lint  saturated  with  a  solution  of  alum,  and  over  the  bleeding 
gum  was  laid  a  thin  piece  of  cotton  stuff,  saturated  in  like  manner. 
The  plate  was  now  placed  in  position  and  firmly  secured.  Tincture 
of  Erigerou  Cauadense  was  given  in  one-drop  doses,  repeated  every 
few  minutes,  and  the  feet  were  placed  in  hot  water,  the  patient  sit- 
ting up.  Hemorrhage  ceased  entirely  in  the  course  of  an  hour,  and 
did  not  recur. 

JVIr.  B.,  the  father  of  this  young  gentleman,  aged  perhaps  50,  suf- 
fered five  days  from  hemorrhage,  under  the  following  circumstances. 
A  wisdom  tooth  of  the  left  upper  jaw  troubling  him,  because  of  its 
great  looseness,  he  applied  to  his  dentist  for  its  removal.  Not  deem- 
ing it  necessary  or  desirable  to  wound  the  gum,  the  practitioner  ex- 
tracted it  without  the  preliminary  step  of  lancing,  and  in  the  act 
was  so  unfortunate  as  to  tear  away  a  small  strip.  Hemorrhage 
was  immediate,  and  more  or  less  continuous.  Monsel's  solution 
being  pi-escribed  by  his  physician,  it  was  employed,  but  w^ith  some- 
what of  the  same  result  as  in  the  son's  case.  On  the  evening  of 
the  fifth  day  I  first  saw  this  case  ;  the  patient  was  much  weakened 
from  the  excessive  discharge,  and  exceedingly  frightened  and  nerv- 
ous. "Washing  away  the  clots,  I  discovered  the  blood  oozing  from 
the  torn  gum,  and  not  at  all  from  the  tooth  socket.  Commenced  im- 
mediately to  give  the  erigeron  in  drop  doses,  repeated  every  minute, 
and  ligatcd  against  the  wound  a  tuft  of  cotton  saturated  in  the  alum- 
water  ;  the  hemorrhage  ceased  entirely  within  ten  minutes,  and  did 
not  recur.  As  an  assurance,  prescribed  the  wine  of  iron,  which  the 
patient  continued  to  take  to  the  amount  of  four  ounces. 

Tinct.  Erigeron  Canadense,  in  cases  of  this  character,  seems  to  be 
a  quite  reliable  haemostatic;  not  entirely  so,  however,  as  I  have 
prescribed  it  where  it  certainly  failed  to  exert  the  slightest  in- 
fluence. 

Opium  and  lead  are  valuable  agents  in  hemorrhagic  conditions — 
a  pill  composed  of  one  grain  of  opium  and  two  grains  of  acetate  of 
lead  will  generally,  if  repeated  each  few  hours,  be  found  entirely 
reliable. 

A  hot  pediluvium  is  an  invaluable  adjunct,  being  not  unfrequently 
alone  sufficient  to  the  control  of  severe  local  hemorrhage. 


GENERAL  REMARKS   ON  EXTRACTION.  237 

The  ordinary  cobweb  of  the  cellar  is  an  excellent  local  hasmostatic ; 
particularly  reliable  is  it  if  saturated  in  water  and  mingled  with 
bayberry  powder.  As  a  local  application  to  large  bleeding  surfaces 
I  know  of  nothing  to  surpass  it.  I  used  this  once  in  the  case  of  an 
infant  laboring  under  profuse  hemorrhage  from  lanced  gums,  and  it 
controlled  the  bleeding  almost  immediately,  although  almost  every 
conceivable  thing  had  been  previously  applied  without  benefit. 

Monsel's  solutions  cannot,  I  feel,  be  too  strongly  objected  to  as 
an  application  in  oral,  and,  indeed,  I  think,  in  any  other  kind  of 
hemorrhage.  Or,  if  they  must  be  used,  the  practitioner  should  never 
trust  them  in  unskillful  hands.  They  certainly  will  check  a  hemor- 
rhage, but  generally  only  temporarily.  With  the  coming  away  of 
the  clot  the  bleeding  is  almost  sure  to  reappear,  while  hemor- 
rhage, secondary  to  the  use  of  the  solution,  is  always  more  difficult 
to  control  than  when  no  such  preparations  have  been  used ;  the 
application  certainly  lowers  the  vitality  of  parts.  The  best  effects 
of  the  Monsel's  solutions  are  secured  by  simply  touching  the 
bleeding  part:  to  do  more  is  to  do  harm.  The  common  mode  of 
saturating  a  tuft  of  cotton  and  packing  it  pell-mell  into  or  against  a 
part,  is  most  reprehensible,  and  should  never  be  practiced. 

Of  the  haemostatic  effect  of  alum-water  I  feel  I  could  scarcely 
say  too  much.  I  always  employ  it  in  the  various  operations  about 
the  mouth,  and  it  seldom  fails.  In  any  ordinary  venous  or  capillary 
hemorrhage,  if  assisted  by  proper  adjuncts,  it  may  commonly  be 
depended  on. 

In  persons  of  known  hemorrhagic  tendencies,  the  extraction  of 
teeth,  as  well  as  the  performance  of  any  surgical  operation,  should 
be  preceded,  when  possible,  by  a  few  days  or  weeks  of  preparatory 
treatment.  Tinct.  of  the  chloride  of  iron,  in  doses  varying  from  10 
to  20  drops,  should  be  given  three  times  a  day  for  one  or  more 
weeks.  Conjoined  with  this  the  patient  may  take  at  the  same 
hours  as  much  Peruvian  bark,  the  red  variety,  as  will  lie  upon  a 
silver  half  dime.  On  the  day  of  operation  three  pills  should  be 
given,  at  intervals  of  one  or  two  hours,  each  containing  one  grain  of 
pulverized  opium  and  two  grains  of  acetate  of  lead.  With  such  pre- 
liminary treatment  little  trouble  need  be  apprehended  from  hemor- 
rhage. 

Eest  is  a  valuable  haemostatic.  A  bleeding  part  should  remain 
as  quiet  as  possible,  and,  if  possible,  be  kept  well  elevated.  Com- 
pression of  a  bleeding  alveolus  or  a  bleeding  gum  can  very  well  be 
effected  by  the  use  of  a  common  bottle-cork ;  plugging  the  socket,  or 


238  ORAL  DISEASES  AND  SURGERY. 

laying  the  cloth  over  the  gum,  cut  a  concavity  into  one  face  of  the 
cork  and  fit  it  over  the  parts ;  it  is  solidly  retained  in  place  simply 
by  closure  of  the  teeth ;  or,  if  the  patient  be  a  child,  the  head  bandage 
may  be  thrown  about  the  jaws. 

Compression  should  be  moderate  and  not  severe,  and  once  made, 
and  the  hemorrhage  thereby  controlled,  should  not  be  too  hastily 
removed 

Luxation  of  the  Inferior  Maxilla. — Occasionally,  as  the  re- 
sult of  a  sudden  movement,  or  an  abnormal  laxity  of  the  ligaments 
of  the  temporo-maxillary  articulation,  the  condyloid  process  falls 
forward  over  the  glenoid  boundary.  The  patient  is  thus  rendered 
unable  to  close  the  mouth,  and  is  said  to  labor  under  luxation.  (See 
chapter  on  Luxation.) 

Local  Anesthetics  in  the  Extraction  of  Teeth. — The  em- 
ployment of  various  local  agents  to  secure  exemption  from  pain  in 
the  operation  of  extraction,  has  of  late  commanded  so  much  atten- 
tion that  no  chapter  on  the  subject  of  such  operations  would  be 
complete  without  reference  to  the  subject. 

The  most  simple  and,  we  may  say,  elementary  application  in  this 
direction,  consists  in  inclosing  in  a  piece  of  bladder,  or  other  conve- 
nient skin,  a  small  portion  of  pounded  ice  and  salt,  and  enveloping, 
for  a  few  moments,  the  part  to  be  operated  on.  To  secure  most 
conveniently  the  effect  of  such  a  process  of  refrigeration,  various 
instruments  have  been  devised,  but  none,  so  far  as  the  application  of 
the  ice  and  salt  is  concerned,  have  been  found  to  answer  any  better 
purpose  than  the  bladder  or  skin  inclosure.  Such  skins  should  consist 
of  two  little  bags,  one  to  rest  upon  the  outer,  the  other  upon  the  inner, 
side  of  the  gum.  To  prevent  pain  from  the  application  of  the  cold, 
the  bags  should  be  brought  gradually  in  contact  with  the  gums ;  or, 
what  will  answer  a  similar  purpose,  the  application  may  be  pre- 
ceded by  ice-cold  water  held  in  the  mouth  for  a  few  moments. 

An  apparatus  designed  and  manufactured  by  Messrs.  Home  & 
Thornwaite,  of  London,  is  said  to  answer  a  very  good  purpose,  and 
is  thus  described :  "  A  required  amount  of  water  is  cooled  down,  by 
means  of  ice  and  salt,  to  about  zero,  in  a  vessel  called  a  refrigerator. 
To  this  vessel  is  attached  another,  called  a  graduator,  containing 
warm  water  at  about  100°,  and  so  constructed  as  to  allow  the  slow 
admixture  of  its  contents  with  the  chilled  water  in  the  refrigerator, 
and  thus  produce  a  gradually  diminishing  temperature,  for  the  pur- 
pose of  preventing  sudden  shock  and  pain  to  the  teeth,  which  a 
direct  application  of  cold  would  inevitably  cause.     A  tube  conveys 


GENERAL  REMARKS   ON  EXTRACTION.  239 

this  graduated  current  into  a  terminal  portion  constructed  of  very- 
fine  membrane,  which  adapts  itself  to  the  form  of  the  gums,  and 
wholly  surrounds  the  tooth  to  be  extracted.  The  fluid  then  passes 
away  through  an  exit  tube.  In  this  manner  a  constant  current  of 
cold,  at  a  decreasing  temperature,  is  made  to  pass  over  the  part, 
abstracting  therefrom  all  heat,  and  consequently  all  feeling." 

The  concentrated  tincture  of  aconite  is  a  useful  local  anaesthetic,  but 
one  that  should  be  used  with  a  considerable  degree  of  caution.  If  a 
portion  of  this  tincture  be  applied  to  one-half  the  lip,  sensibility  will 
be  so  interfered  with  that  a  goblet  placed  to  the  parts  will  appear 
as  if  broken. 

A  mixture  of  chloroform  and  laudanum  in  equal  parts  is  much 
lauded  by  some.  To  apply  this,  it  is  only  necessary  to  saturate  a  tuft 
of  cotton,  and  lay  it  against  the  tooth  to  be  extracted. 

Electro-galvanism  claimed  at  one  time  a  good  share  of  attention. 
Its  application  consists  in  applying  one  pole  of  a  battery  to  the  for- 
ceps, while  the  other  is  held  in  the  hand  of  the  patient ;  a  gentle 
current  is  then  to  be  let  on,  during  the  passage  of  which  the  tooth  is 
extracted.  This  mode  of  effecting  local  antesthesia  is  still  practiced 
by  very  many ;  but  I  must  say  that,  in  my  hands  and  in  the  hands 
of  many  experienced  friends,  it  has  proved  a  failure.  Not  that  it  is 
attempted  to  deny  that  in  certain  cases  it  does  not  seem  somewhat 
to  obtund  sensibility,  but  in  the  majority  of  instances  it  either  does 
no  good  at  all  or  adds  the  discomfort  of  the  current  to  the  pain  of 
the  operation. 

The  application  of  the  spray  of  ether  and  rhigolene  is  the  latest, 
and  perhaps  the  most  worthy  and  reliable,  of  the  local  anaesthetics ; 
certainly  one  may  say  reliable  when  employed  for  operations  of 
limited  extent  about  the  soft  parts,  but  as  to  its  equal  reliability  in 
tooth  extraction,  my  experience  has  not  so  well  satisfied  me.  With 
these  agents  I  have  performed  many  operations  as  thus  applied, 
in  the  way  of  the  removal  of  sebaceous  and  other  superficial  tumors, 
the  opening  of  abscesses,  carbuncles,  and  similar  operations,  and 
the  result  has  been  everything  I  could  have  desired ;  but  in  its 
application  to  the  teeth,  the  obtunding  of  the  sensibility  has  not  by 
any  means  been  so  marked ;  particularly  has  this  been  the  case 
where  rhigolene  was  used. 

The  process  of  freezing  a  part  through  the  known  refrigerant  power 
of  evaporating  ether  seems  first  to  have  suggested  itself  to  Dr. 
Richardson,  of  London.  An  instrument,  invented  by  this  gentle- 
man for  the  accomplishment  of  such  an  end,  is  here  exhibited, 
forms  of  bellows  for  both  hand  and  foot  being  represented. 


240 


ORAL  DISEASES  AND  SURGERY. 


For  the  spraying  of  any  plain  surface  the  simple  straight  tube  is 
all  that  is  necessary.  For  the  teeth  the  double  sprayer,  as  seen  in  the 
drawin"-,  is  used;  with  this  instrument  a  continuous  vapor  is  cast 
both  upon  the  outer  and  the  inner  face  of  the  gum,  and  congelation 
is  rapidly  induced. 

Fig.  55.— Sprat  Apparatus — Hand  Instrument. 


In  using  this  hand  instrument,  the  operator  himself  should  not 
work  the  pump.  A  very  few  moments'  compression  of  the  ball 
renders  the  hand  shaky  and  unmanageable. 

Upon  this  instrument  of  Dr.  Richardson's,  modifications  have 
already  been  made :  of  these,  one  by  Messrs.  Codman  and  Shurt- 
leff,  of  Boston,  has,  perhaps,  attracted  most  attention  ;  it  certainly 
seems  to  divide  the  ether  more  infinitesimally,  thus  insuring  a  more 
complete  vaporization ;  but  it  has  a  weak  point,  in  that  the  tube 
seems  frequently  to  freeze  or  choke  up,  an  accident  that  does  not 
occur  with  Dr.  Richardson's  instrument. 

An  objection  urged  to  the  use  of  extreme  cold  as  thus  induced,  is, 
that  injury  is  done  to  the  soft  parts,  as  it  is  thought  will  be  mani- 
fested in  inability  to  unite  wounds  happily  and  easily.  That  such 
objection  is,  however,  not  valid,  I  have  satisfactorily  proven,  for,  if 
anything,  parts  thus  operated  on  have  united  better  and  with  less 
inflammatory  reaction  than  has  obtained  where  the  spray  has  not 
been  used. 


GENERAL  REMARKS  ON  EXTRACTION.  241 

Fig.  56. — Spray  Apparatus — Foot  Instrument. 


Rhigolene,  or  hydro-carbon,  manufactured  from  coal  oil,  and  much 
vaunted  by  some,  has  not,  in  my  hands,  proven  so  satisfactory  as 
ether.  It  certainly  freezes  a  part  more  quickly  than  this  latter 
agent,  but  this  does  not  seem  alone  to  be  the  object,  as  anaesthesia  is 
not  nearly  so  complete. 

16 


CHAPTER    XV. 

GENERAL     ANESTHESIA. 

"  So  long  as  pain  is  an  evil,  and  ease  a  good,— so  long,  in  other 
words,  as  man  is  man, — must  any  means  be  prized  that  is  capable  of 
achieving  the  latter  by  the  abolition  of  the  former.  As,  then,  the 
pain  of  surgical  operations  is  certainly  of  the  most  terrible  of  its 
class,  and  it  is  no  matter  of  doubt  that  agents  exist  which  possess 
the  power  of  abolishing  this  pain,  what  remains  for  consideration  is 
not  so  much  whether  this  means  shall  be  hailed  as  a  matchless  and 
priceless  discovery  and  be  cherished  and  adopted  as  a  blessed  thing, — 
this  appreciation  has  been  made,  this  adoption  has  been  consecrated 
bv  almost  universal  practice, — what  remains  for  consideration  is, 
whether  the  good  is  a  pure  good,  or  is  counterbalanced  by  evil. 

"  The  obvious,  open,  palpable,  glorious  good  of  anaesthesia,  and 
particularly  ether  anaesthesia,  is  to  deliver  the  wretched  victim  of 
surgical  disease  from  the  additional  torture  of  pain,  while  seeking 
the  goal  of  health  through  the  portals  of  chirurgery.  The  evils 
that  have  been  said  to  follow  or  accompany  this  good  have,  how- 
ever, been  regarded  by  some  as  of  so  serious  a  character  as  not  only 
to  induce  them  to  reject  general  anaesthesia  in  their  own  practice,  but 
to  denounce  it  publicly  as  a  means  that  should  not  obtain  with  sci- 
entific and  conscientious  men. 

"  We  confess  that  we  are  surprised  whenever  we  hear  these  ex- 
pressions, and,  strange  as  it  may  seem,  there  are  even  now  enough 
to  give  expression  to  them.  Of  the  hundreds  and  thousands,  we 
might  say  hundreds  of  thousands,  who  have  taken  ether  to  insensi- 
bility, we  have  been  unable  to  discover,  after  the  most  extended  in- 
quiries, a  single  case  which  resulted  in  death,  or  left  behind  it  conse- 
quences of  serious  importance  that  were  certainly  attributable  to  it. 
In  a  small  proportion  of  cases  there  have,  no  doubt,  been  some  un- 
pleasant results,  such  as  temporary  depression  of  the  vital  powers ; 
headache,  more  or  less  considerable,  for  some  hours,  or  even  days  ; 
hysterical  excitement  in  women  for  a  similar  length  of  time ;  slight 
bronchial  irritation,  nausea,  and  sickness,  and  some  other  slight  af- 
(242) 


GENERAL  ANJESTHESIA.  243 

fections  ;  but  the  proportion  of  patients  suffering,  even  in  this  slight 
manner,  has  been  extremely  small,  indeed  wonderfully  small,  when 
we  consider  the  indiscriminate  manner  in  which  the  practice  has 
been  had  recourse  to,  with  bad  ether  and  bad  manipulators.  Indeed, 
that  so  very  few,  and  such  trifling  accidents  have  occurred  in  such  a 
state  of  things,  is  most  convincing  proof  of  the  general  safety  of  the 
practice.  For,  in  considering  the  entire  incompetence  of  the  many 
who  are  in  daily,  fearless  employment  of  the  agent,  so  far  from  these 
uniformly  innocent  results  being  anticipated,  one  might  very  natu- 
rally look  for  others  of  a  very  different  kind.  We  have  ourselves 
been  constantly  looking  for  ill  consequences,  and  we  are  still  prepared 
to  find  them ;  but  when  they  arrive,  if  ever  they  now  are  to  arrive, 
we  shall  have  to  consider  well,  before  condemning  the  agent,  whether 
the  event  was  a  necessary  consequence  of  its  use,  or  merely  an  acci- 
dental result  from  its  abuse." 

The  preceding  very  impartial  and  terse  consideration  of  the  gen- 
eral question  of  anaesthesia,  as  reference  is  had  to  its  production  by 
sulphuric  ether,  we  find  in  a  British  exchange.  The  question,  "  To 
what  are  accidents  (if  accidents  there  are)  attributable?"  is  naturally 
suggested,  and  would  excite  in  the  mind  a  desire  to  enter  on  the 
consideration  of  a  subject  fraught  with  such  importance,  before 
taking  up  its  use  or  joining  in  the  cry  of  those  who  abuse. 

Such  consideration  I  propose  to  make  the  subject  of  this  chapter, 
and  trust  that  not  a  little  personal  experience  enjoyed  will  enable 
me  to  present  it  with  some  degree  of  clearness.  We  first  consider 
sulphuric  ether. 

An  agent,  refreshing  in  itself,  may,  in  improper  hands,  become  a 
source  of  ill ;  this  truth  embraces  the  whole  Materia  Medica. 

What  is  sulphuric  ether? 

"  When  equal  weights  of  rectified  spirits  and  oil  of  vitriol  are 
mixed  in  a  retort,  the  latter  connected  with  a  good  condensing  ar- 
rangement, and  the  liquid  heated  to  ebullition,  a  colorless  and  highly 
volatile  liquid,  long  known  under  the  name  of  ether,  or  sulphuric 
ether,  distils  over.  The  process  must  be  stopped  as  soon  as  the 
contents  of  the  retort  blacken  and  froth,  otherwise  the  product  will 
be  contaminated  with  other  substances  which  then  make  their  ap- 
pearance. The  ether  obtained  may  be  mixed  with  a  little  caustic 
potash,  and  redistilled  by  a  very  gentle  heat. 

"Pure  ether  is  a  colorless,  transparent,  fragrant  liquid,  very  thin 
and  mobile.  Its  sp.  gr.  at  60°  is  about  120  ;  it  boils  at  96°  under 
the  pressure  of  the   atmosphere,  and  bears,  without  freezing,  the 


244  ORAL  DISEASES  AND  SURGERY. 

severest  cold.  When  dropped  on  the  hand  it  occasions  a  sharp 
sensation  of  cold,  from  its  rapid  volatilization.  Ether  is  very  com- 
bustible; it  bm-ns  with  a  white  flame,  generating  water  and  carbonic 
acid.  Although  the  substance  is  among  the  lightest  of  liquids,  its 
vapor  is  very  heavy,  having  a  density  of  2-586.  Mixed  with  oxygen 
gas  and  fired  by  the  electric  spark,  or  otherwise,  it  explodes  with 
the  utmost  violence.  Preserved  in  an  imperfectly-stopped  vessel, 
ether  absorbs  oxygen  and  becomes  acid,  from  the  production  of  acetic 
acid.  This  attraction  for  oxygen  is  increased  by  elevation  of  tem- 
perature." (Foumes.) 

Dr.  Jackson's  formula  for  the  preparation  of  ether  for  anaesthetic 
purposes  is,  we  believe,  as  follows:  procuring  the  strongest  and 
purest  rectified  sulphuric  ether — that  just  described — wash  it  well, 
to  get  clear  of  any  acids,  then  decant  from  the  water,  drying  it  with 
chloride  of  calcium,  to  free  it  of  any  water  that  might  otherwise 
remain  from  the  washing. 

This,  however,  is  but  a  single  formula.  Different  chemists  gain 
the  same  ends  through  different  processes.  It  is  for  the  surgeon 
to  buy  of  a  reliable  druggist  rather  than  attempt,  himself,  the 
preparation. 

This,  then,  is  ether,  an  agent  which  experience  demonstrates  that, 
breathed  into  the  lungs,  will  produce  insensibility.  To  exhibit  ether 
successfully,  four  essentials  seem  necessary: 

1st.  That  the  ether  should  be  very  pure. 

2d.  That  the  vehicle  upon  which,  or  with  which,  the  agent  is  ex- 
hibited, should  be  of  such  character  that  full  volume  of  atmospheric 
air  is  allowed  to  pass  through  the  ether  into  the  lungs. 

3d.  That  the  vapor  of  the  ether  be  properly  diluted,  given  for  the 
first  few  inspirations  comparatively  weak,  and  increased  in  strength 
as  the  glottis,  air-passages,  and  lungs  can  bear  it. 

4th.  That  insensibility  be  produced  as  quickly  as  the  system  will 
bear,  as  evinced  by  obvious  signs. 

A  cone-shaped,  close  sponge  is  the  best  means  for  administering 
ether.  This  possesses  every  advantage,  except  economy  in  the  ad- 
ministration, without  having  any  of  the  common  faults.  From  two 
to  five  minutes  will  be  found  the  average  time  necessary  to  pro- 
duce the  full  effect  of  perfect  sleep,  while  cases  will  present  them- 
selves whei-e  double  this  time  will  be  required,  and  where,  indeed, 
it  may  be  necessary  to  combine  with  the  ether  the  more  powerful 
effect  of  chloroform,  or  even  to  employ  the  undiluted  chloroform. 
From  an  article  emanating  from  a  gentleman  of  snuch  experience  in 


GENERAL   ANESTHESIA.  245 

anaesthetic  agents,  we  have  the  following:  "It  is  possible  to  in- 
spire three,  four,  nay,  ten  times  the  quantity  of  ether  capable  of 
producing  sleep,  without  this  state  being  produced,  provided  the 
vapor  be  taken  in  a  too  diluted  form ;  and  we  believe  this  over-dilu- 
tion and  its  consecpent  protracted  inhalation  is  a  frequent  cause  of 
the  excitement  which  supervenes  In  the  practice  of  many  persons, 
while  it  so  rarely  shows  itself  in  that  of  others.  In  these  cases  the 
patient  may  be  made  drunk ;  drunk  in  the  first  degree,  but  not  dead 
drunk,  the  condition  required  for  surgical  purposes." 

It  will  be  remarked,  let  us  notice  in  passing,  that  one  of  the  most 
common  objections  of  the  opponents  of  ether  lies  at  this  door — this 
supervening  state  of  excitement  instead  of  the  desired  state  of  stupor ; 
but  does  not  the  question  again  very  pertinently  apply.  Is  the  fault 
with  the  agent,  or  with  the  operator  ? 

The  idea  is  to  be  conveyed  that  the  effects  of  sulphuric  ether  and 
the  common  alcoholic  beverages  are  the  same.  The  effects  of  alco- 
holic liquids  are  too  well  known  to  require  minute  description.  We 
have,  first,  the  state  of  exhilaration,  which  gradually  changes  to  com- 
plete stupefaction  or  narcotism.  The  last  state,  the  result  probably 
of  a  narcotized  state  of  the  .brain.  Just  so  acts  ether,  yet  passing 
through  its  various  stages  more  quickly,  the  result  of  its  being 
poured  in  a  continuous  and  undiluted  stream  upon  the  heart  and 
brain.  The  ether  is  no  sooner  absorbed  than  the  blood  charged  with 
it  passes  to  the  left  side  of  the  heart,  and  immediately  thereafter  is 
circulated  through  the  coronary  vessels,  the  carotid  and  vertebral 
arteries,  and  thus  pervades  the  tissue  of  all  parts  of  the  heart,  as 
well  as  of  every  portion  of  the  brain.  A  writer,  in  an  influential 
dissertation,  presents  an  example  in  this  wise : 

"  Suppose,  to  take  an  extreme  illustration,  that  the  blood  was  as 
capable  of  absorbing  as  much  ether  as  water  can  combine  with,  or 
one-tenth  its  own  weight.  If,  then,  we  suppose  the  blood  in  the 
lungs  was  impregnated  to  this  extent,  it  would  be  applied  in  that 
state  to  the  heart  and  brain ;  whereas,  if  the  blood  in  the  stomachic 
vessels  was  impregnated  to  the  same  extent  with  ether,  before  reach- 
ing the  liver  it  would  have  mingled  with  more  than  its  own  mass 
of  pure  blood  from  the  splenic  and  mesenteric  veins.  The  tenth 
would  then  become  a  twentieth,  and,  on  the  blood  leaving  the  liver 
and  joining  the  larger  current  of  the  infei'ior  cava,  the  twentieth 
would  become  a  fiftieth  or  sixtieth  ;  a  further  dilution  would  take 
place  at  the  confluence  with  the  superior  cava,  so  that  the  blood,  on 
reaching  the  heart  and  brain,  instead  of  containing  one-tenth  part  of 


246  ORAL   DISEASES  AND  SURG  ERF. 

absorbed  ether,  could  not  contain  as  much  as  one-hundredth.  When, 
therefore,  the  same  quantity  of  ether,  or  any  absorbable  substance, 
is  taken  up  from  the  lungs  and  from  the  stomach,  it  must,  in  the 
former  case,  be  applied  to  the  tissue  of  the  heart  and  brain,  in  a  state 
of  concentration  at  least  ten  times  greater  than  the  latter,  and  will 
therefore  act  on  these  organs  with  more  suddenness  and  energy." 

The  evanescence  of  the  effect  of  ether,  when  compared  with  alco- 
hol, is  explained  by  a  momentary  consideration  of  the  different  man- 
ner of  absorption.  During  the  inhalation  of  ether,  as  we  have  just 
seen,  the  charged  blood  is  applied  to  the  heart  and  brain,  while  the 
blood  circulating  in  the  lower  parts  of  the  body  contains  a  much 
smaller  proportion  of  it.  Now,  on  stopping  the  inhalation,  the  blood 
in  the  heart  and  brain  speedily  passes  off  by  the  veins,  and  is  suc- 
ceeded by  the  comparatively  pure  blood  coming  from  the  lower 
regions  of  the  body,  and  so  the  narcotic  symptoms  disappear. 

"  It  is  far  otherwise  when  alcohol  is  absorbed  from  the  stomach, 
for  the  whole  mass  of  blood  must  be  impregnated  with  it  before  a 
highly  charged  blood  can  be  applied  to  the  heart  and  brain ;  and 
then  the  effect  continues  for  many  hours,  till  the  alcohol  has  been 
thrown  out  of  the  system  by  the  lungs  and  skin.  With  respect  to 
ether,  it  must  not  be  supposed  that  on  the  subsidence  of  the  nar- 
cotism it  disappears  from  the  body ;  for  it  is  merely  weakened  in  its 
effects  by  being  diffused  over  the  whole  mass  of  blood.  This  is 
obvious,  from  the  smell  of  the  breath  for  many  hours,  and  from  its 
frequently  causing  copious  perspiration." 

Does  not  the  question  here  suggest  itself.  If  the  effects  of  ether 
and  the  common  alcoholic  beverages  are  so  nearly  alike,  why  the 
great  dread  of  the  one  and  the  entire  fearlessness  with  the  other? 
Would  not  the  answer  seem  to  be  something  of  this  kind  ?  Men 
when  etherized  are  as  dead  drunk — our  eyes  are  not  well  accustomed 
to  seeing  them  but  partly  drunk.  In  this  state  they  excite  amuse- 
ment— in  the  state  of  profound  drunkenness  they  have  always 
aroused  our  fears  for  their  recovery.  Associations  have  great 
weight. 

The  immediate  and  obvious  effects  of  etherization  on  the  individ- 
ual hardly  require  notice,  as  they  must  be  familiar  to  all  our  readers, 
if  not  from  a  personal  experience,  certainly  from  observation  upon 
others.  "All  the  usual  phenomena  of  the  deepest  sleep  supervene, 
gliding  often  into  the  profoundness  of  sopor  and  verging  occasion- 
ally upon,  if  not  actually  lapsing  into,  coma.  The  voluntary  mus- 
cles become  suddenly  relaxed,  the  jaw  falls,  the  arms  hang  down, 


GENERAL  ANESTHESIA.  247 

the  eyes  roll  upward  under  the  lid,  the  respiration  becomes  slow  and 
labored,  and  the  face  becomes  either  very  pale  or  morbidly  flushed ; 
the  aspect  of  things  is  truly  such  as  can  hardly  be  contemplated  for 
the  first  time  without  alarm :  the  individual  seeming,  to  the  com- 
mon eye,  to  be  sinking  into  the  sleep  of  death." 

It  is  impossible,  says  another  observer,  to  see  a  single  case  of  ether- 
ization without  being  struck  with  its  resemblance  to  asphyxia — and 
experiments  exhibit  a  real  relation  between  the  two.  But  in  ordinary 
asphyxia,  the  nervous  system  loses  its  power  under  the  influence  of 
black  blood,  or  blood  deprived  of  its  oxygen.  But  in  etherization  it 
does  so  under  the  direction  of  this  singular  agent.  This  is  really 
all  the  difference,  for  in  both  there  is  the  same  loss  of  sensation  and 
voluntary  motion,  and  the  same,  at  least  temporary,  persistence  of 
the  respiratory  movements.  In  one  word,  there  is  the  same  survival 
of  the  medulla  oblongata  over  the  spinalis. 

"Etherization  exhibits  to  us  the  entire  mechanism  of  asphyxia — we 
mean  the  successive  deaths  of  the  various  nervous  centers.  It  iso- 
lates, just  as  mechanical  experiments  do,  the  intellectual  powers, 
the  co-ordination  of  the  movements,  sensibility,  motility,  life.  The 
isolation  of  life — this  point,  this  vital  knot  of  the  nervous  system — 
forms  the  most  striking  point  of  the  experiments. 

"In  an  etherized  animal  one  point  alone  survives,  and  while  it  does 
so,  all  others  retain  at  least  a  latent  life,  and  may  resume  their  active 
life  ;  this  point  once  dying,  all  dies." 

Throwing  out  of  immediate  consideration  the  idiosyncrasies,  let 
us  for  a  few  moments  consider  the  question  of  the  general  safe  ex- 
hibition of  the  agent. 

The  safest  agent  may  be  made  a  source  of  ill :  as  the  intruder  on 
the  physical  laws  of'  his  organism  must  suffer  the  consequences  of 
his  ignorance  or  temerity,  so  may  an  agent  be  made  an  injury  by 
its  abuse.  As  the  imbibition  of  alcoholic  beverages  may  be  carried 
to  a  point  beyond  which  the  life  principle  reacts  not,  just  so,  and  as 
the  warmest  supporters  of  the  anesthetics  would  have  impressed, 
may  ether  be  made  an  instrument  of  irreparable  injury,  blasting  and 
destroying  where  it  was  designed  to  refresh  and  save. 

To  describe  or  lay  down  certain  reliable  rules,  applicable  in 
all  cases,  of  the  process  of  etherization,  is  an  impossibility.  The 
presentments  of  conditions  in  various  individuals  so  materially 
differ,  that  any  but  rules,  the  result  of  a  general  knowledge  of  the 
agent,  a  comprehension  of  physiological  laws  and  pathological  alter- 
nations, were  charlatanism  to  act  upon.     One  person,  as  Dr,  Snow 


248  ORAL  DISEASES  AND   SURGERY. 

remarks,  "shall  become  impassable  as  the  subject  on  the  disseet- 
ing-tablo ;  another  talks  incoherently  or  mirthfully,  replies  to  ques. 
tions,  or  obeys  directions ;  others  utter  exclamations  of  pain,  which 
they  afterward  retain  no  reminiscence  of  having  felt ;  and  others 
ao-ain  declare  that  they  have  suffered  pain  but  felt  themselves 
powerless  for  its  expression.  Finally,  in  not  a  few,  ungovernable, 
violent  or  convulsive  action  takes  place,  quite  adverse  to  the  per- 
formance of  any  delicate  surgical  operation.  With  some  an  utter 
oblivion  is  induced  ;  while  others,  while  undergoing  all  the  apparent 
torture  of  a  prolonged  dissection,  are  reveling  in  the  realms  of 
memory  and  in  the  fields  of  imagination."  M.  Jobart  and  other  ob- 
servers have  attempted  to  lay  down  three  distinct  stages  in  its 
effects,  according  to  the  prolongation  of  the  etherization.  1.  That 
of  incoherence,  agitation,  or  delirium,  as  the  case  may  be.  2.  Ac- 
celeration of  the  pulse,  with  loss  of  sensibility  and  loss  of  power. 
3.  Exhaustion  and  coldness  of  the  surface.  As  we  remarked,  the 
matter  cannot  thus  be  methodically  laid  down,  for  it  is  quite  certain 
that  any  of  these  conditions  may  be  induced,  in  different  individuals, 
by  very  various  doses  of  ether ;  while  others,  again,  are  susceptible 
of  only  the  first  degrees,  to  appearances,  and  yet  enjoy  an  immunity 
from  suffering  during  operations.  Even  the  quickened  condition  of 
the  pulse  and  respiration,  and  that  almost  universally  employed 
criterion,  the  stationary  condition  of  the  pupil,  may  all  deceive  in 
the  supposed  impression  produced. 

Various  of  the  French  Academicians  some  years  back  instituted 
a  series  of  experiments  upon  animals,  for  the  purpose  of  determining 
the  mode  and  order  in  which  the  various  portions  of  the  cerebro- 
spinal system  were  influenced  during  inhalation.  The  following  are 
some  of  the  conclusions  arrived  at  by  the  veteran  vivisector,  Baron 
Flourens : 

"  The  action  of  ether  upon  the  nervous  centers  follows  in  a  given 
course.  It  acts,  first,  upon  the  cerebral  lobes,  disturbing  the  intellect. 
It  acts,  secondly,  upon  the  cerebellum,  deranging  the  equilibrium  of 
the  movements  of  the  animal.  Thirdly,  it  acts  upon  the  medulla 
spinalis,  in  which  it  extinguishes,  successively,  the  sensory  and  mo- 
tive principles ;  and,  lastly,  it  acts  upon  the  medulla  oblongata, 
where  arrived,  life  becomes  extinct." 

To  produce  the  best  effects  of  sulphuric  ether,  it  is  of  the  first 
consequence  that  an  entirely  reliable  article  be  employed.  "For 
myself,"  says  Dr.  Robinson,  of  London,  "I  feel  convinced  that  many 
of  the  failures  that  have  occurred  in  its  administration  in  some 


GENERAL  ANESTHESIA.  249 

measure  may  be  attributed  to  the  imperfect  preparation  of  the  fluid. 
I  have  myself  obtained  ether  of  various  specific  qualities  from  dif- 
ferent chemists ;  and  on  one  occasion,  requiring  an  extra  quality  for 
a  series  of  experiments,  the  gentleman  supplying,  being  out  of  that 
quality  he  had  generally  furnished,  sent  some  of  a  different  kind 
which  he  had  in  his  establishment,  which  was  administered  in 
two  cases.  I  found,  however,  I  could  only  produce  partial  uncon- 
sciousness, not  insensibility  to  pain,  and  therefore  deferred  the 
operations,  which  were  upon  the  teeth.  I  afterward  procured  some 
of  the  first  quality  ether,  and  employed  it  in  the  same  case  with 
success." 

The  effect  of  a  bad  article  of  ether  is  not  only  the  inability  on 
the  part  of  the  operator  to  produce  more  than  a  partial  unconscious- 
ness, but  it  is  almost  certain  to  produce  nausea,  giddiness,  and 
prostration.  If  a  good  article  cannot  be  procured,  better  use  none 
at  all. 

The  quantity  of  ether  that  may  be  given  to  an  individual  patient 
is  a  matter  for  the  practitioner '  to  decide  upon  in  connection  with 
each  case.  It  is  impossible  to  fix  the  dose  of  vapor  that  will  be 
required  to  produce  given  effects  upon  any  patient,  neither  is  it  always 
an  easy  matter  to  decide  when  just  enough  has  been  administered. 
We  cannot  rely  implicitly  on  the  state  of  the  pupil  or  pulse,  or  upon 
what  is  considered  by  so  many  as  the  exact  indication,  namely,  the 
insusceptibility  of  the  eyelids  to  impressions  made  by  striking  the 
hairs.  Perhaps  the  changes  in  the  breathing  are  the  most  reliable 
signs :  these  certainly  influence  me  most ;  so  long  as  breathing  con- 
tinues easy  and  natural,  little  danger  is  to  be  anticipated,  but  the 
moment  it  becomes  labored,  one  is  to  precede  or  recede  cautiously.  In 
etherizing  a  patient  let  the  operator  watch  the  pulse,  the  expression, 
and  the  respiration.  So  long  as  these  give  no  counter-indications, 
the  exhibition  may  be  carried  forward  to  the  end  desired. 

As  to  a  question  of  the  continuance  of  a  patient  in  the  anaesthetic 
condition,  I  think  it  will  be  found  the  proper  rule  to  make  the  time 
just  as  short  as  possible;  that  is  to  say,  as  the  continuance  of  the 
exhibition  of  the  agent  is  concerned.  If  an  operation  to  be  per- 
formed in  the  anaesthetic  condition  may  be  completed  in  five,  ten,  or 
fifteen  minutes,  it  is  not  good  policy  to  prolong  it,  and  with  it  the 
continued  administration  of  the  ether  to  a  half  or  a  full  hour.  That 
there  is,  however,  any  imperative  or  absolute  necessity  to  hurry 
through  an  ether  case  is  not  at  all  implied.  I  have  known  a  patient 
kept  continuously  under  ether  for  forty-two  hours ;  and  in  obstetrical 


250 


ORAL  DISEASES  AXD   SURGERY. 


practice,  ten  or  twelve  hours  of  anesthesia  is  not  at  all  unfrequent. 
I  only  contend  that  it  is  neither  necessary  nor  prudent  to  prolong, 
without  object,  the  condition.  Where,  however,  such  a  prolonged 
action  is  demanded,  it  is  to  be  secured,  not  by  keeping  the  saturated 
sponge  constantly  applied  over  the  air-passages,  but  only  at  such 
intervening  periods  as  is  necessary  to  preserve  the  anaesthesia. 

The  condition  of  the  temperature,  as  might  be  inferred,  has  much 
to  do  in  prolonging  or  shortening  the  time  commonly  considered 
necessary  to  place  a  patient  in  a  state  of  sleep.  Dr.  Snow  procured, 
from  experiments,  the  following  results : 

One  hundred  cubic  inches  of  air,  saturated  with  the  vapor  of 
ether,  at  a  temperature  of 

44°  would  contain  27     cubic  inches  of  vapor. 
54  "  24-3 

64  "  43-3 

74  "  53-6 

84  "  66-6 

Being  doubled  by  a  rise  of  only  thirty  degrees ;  or  in  other  words, 
we  perceive  that  if,  at  a  temperature  of  84°  Fahrenheit,  we  employed 
two,  or  two  and  a  half  minutes  in  affecting  a  person  to  the  state 
desired,  at  a  temperature  thirty  degrees  less  we  would  require 
from  four  and  a  half  to  six  minutes  to  have  the  same  result. 

Concerning  the  idiosyncrasies,  I  would  speak  my  own  experience 
by  saying  that  I  have  never  yet  met  with  a  person  who  I  thought 
might  not  take  ether,  or  ether  in  combination  with  chloroform.  The 
London  Medical  Gazette  considers  its  use  inadmissible  where  there 
is  a  tendency  to  apoplexy,  epilepsy,  and  also  in  plethoric  individuals. 
Another  intelligent  source  says  that  persons  presenting  the  slight- 
est signs  of  being  cataleptic  should  be  viewed  as  idiocratical.  Per- 
sons while  under  the  influence  of  liquor,  it  is  generally  esteemed, 
should  be  viewed  for  the  time  as  not  fit  subjects. 

In  a  conversation  with  Dr.  J.  B.  F.  Flagg,  had  several  years  back, 
that  experienced  man  told  me  he  believed  in  no  idiosyncrasies,  ex- 
cept it  might  be  a  very  high,  nervous  temperament ;  remarked  that 
he  had  administered  ether  to  the  infant  of  thirty-six  hours  and  to 
persons  in  extreme  old  age ;  had  given  it  to  the  robust  and  the 
weak,  the  plethoric  and  the  consumptive ;  had  used  it  in  all  states 
of  pregnancy,  except  that  stage  known  as  quickening;  would  also 
exhibit  it  here,  but  would  feel  called  on  to  exercise  more  than  ordi- 
nary care.  Seeming  idiosyncrasies  might  generally,  he  thought, 
be  explained  by  an  examination  of  the  operator's  ignorance  of  the 


GENERAL   ANESTHESIA.  251 

agent.  The  faith  of  this  gentleman  in  the  perfect  safety  of  the  use 
of  ether  is  so  great  that  he  remarked  he  would  not  hesitate  to  use 
it  where  there  had  been,  or  was,  aneurism  of  the  aorta.  The 
opinion  of  Di*.  Flagg  concerning  the  non-existence  of  idiosyncrasies 
is  to  be  taken  before  that  of  most  persons  either  of  this  country  or 
Europe.  His  oppoi'tunities  for  observation  have  not  been  surpassed 
by  those  of  any  other  person,  and  perhaps  equaled  by  few.  The 
work  published  by  him  in  1854,  long  before  his  retirement  from 
practice,  has  not,  up  to  the  present  day,  been  advanced  on,  and  is 
an  heirloom  to  be  valued  by  those  to  whom  his  industry  has  left  it. 


CHAPTER    XYI. 

GENERAL     ANESTHESIA. 

From  the  consideration  of  sulphuric  ether  we  may  pass  to  an  in- 
vestigation of  the  character  and  merits  of  the  perchloride  of  formyle, 
or  chloroform.  This  agent  is,  without  any  doubt,  the  most  power- 
ful and  reliable  of  the  anaesthetics;  but,  unfortunately,  it  possesses 
qualities  which  render  it  not  unfrequently  fatal  to  life,  and  there- 
fore make  it  of  less  value  than  the  one  we  have  been  just  con- 
sidering. No  person  should  employ  chloroform  who  is  not  prepared 
to  meet  many  emergencies. 

To  procure  chloroform,  the  chemist  takes  of  chlorinated  lime  say 
(to  take  a  common  formula),  Ibsiv;  rectified  spirits,  Oss;  water,  Ox; 
chloride  of  calcium,  broken  in  pieces,  5j-  Put  the  lime,  first  mixed 
with  water,  into  a  retort,  and  add  the  spirits,  so  that  the  mixture 
may  fill  only  the  third  part  of  the  retort.  Then  heat  them  in  a 
sand-bath,  and  as  soon  as  ebullition  begins  withdraw  the  heat  as 
quickly  as  possible,  lest  the  retort  should  be  broken  by  the  sudden 
increase  of  heat.  Let  the  liquor  distill  into  the  receiver  so  long 
as  there  is  nothing  which  subsides,  the  heat  being  reapplied,  if 
necessary.  To  the  distilled  liquid  add  a  quarter  of  the  water,  and 
shake  them  all  well  together.  Carefully  separate  the  heavier  por- 
tion, which  subsides,  and  add  the  chloride  to  it,  and  frequently 
shake  them  for  an  hour.  Lastly,  let  the  liquid  distill  again  from  a 
glass  retort  into  a  glass  receiver. 

In  appearance  chloroform  resembles  the  freshest  water  of  the 
mountain-spring ;  to  the  taste  it  is  hot  and  very  sweet ;  to  the 
nostril  it  has  much  the  odor  of  the  common  strawberry.  When 
dropped  upon  linen  it  evaporates  most  quickly,  leaving,  if  pure,  no 
stain  or  sign  behind.  In  weight  it  is  quite  one-half  heavier  than 
water,  and,  as  its  vapor  is  concerned,  is  four  times  heavier  than  at- 
mospheric air. 

The  smell  of  chloroform,  says  Dr.  Snow,  should  be  esteemed  one 
of  the  best  tests  of  its  purity  and  identity.  When  dropped  on  the 
hand  it  should  quickly  evaporate,  leaving  not  the  least  smell  or 
(252) 


GENERAL  ANESTHESIA.  253 

moisture  behind.  If  a  disagreeable  odor  remains  on  the  hand  after 
the  evaporation,  the  chloroform  has  probably  been  made  from  im- 
pure spirits,  or  even  from  wood  or  acetone,  and  is  therefore  unfit  for 
medicinal  purposes.  When  chloroform  becomes  decomposed  from 
any  cause,  it  acquires  a  greenish-yellow  color,  and  gives  off  chlorine 
and  hydrochloric  acid,  so  that  the  alteration  is  at  once  apparent. 
When  chloroform  is  pure,  it  has  no  reaction  on  test  paper,  but  is 
quite  neutral.  The  best  way,  according  to  Dr.  Snow,  to  detect  a 
small  quantity  of  hydrochloric  acid  in  it,  is  to  moisten  a  slip  of  blue 
litmus  paper  with  distilled  water,  and  hold  it  just  within  the  neck 
of  the  bottle  exposed  to  the  vapor.  If  sulphuric  acid  should  be 
present,  it  may  be  discovered  by  agitating  the  chloroform  with  dis- 
tilled water  and  adding  nitrate  of  baryta. 

Chloroform  maybe  degraded  by  admixture  with  alcohol,  and  this 
can  be  done  without  making  any  perceptible  change  in  its  appear- 
ance: its  specific  gravity,  however,  is  thereby  lowered;  and,  accord- 
ing to  M.  Mialhe,  the  foreign  presence  is  most  simply  detected  by 
adding  to  the  suspected  fluid  a  small  quantity  of  water,  when  a 
milky  opacity  results. 

Chloroform,  as  the  heart's  action  is  concerned,  is  a  powerful  seda- 
tive. In  nearly  if  not  quite  all  the  fatal  cases  resulting  from  the 
administration  of  this  agent,  cardiac  syncope  has  been  the  cause  of 
death ;  and  in  a  very  small  minority  of  the  cases  indeed  has  there 
been  any  evident  interference  with  the  process  of  respiration.  This 
fact  is  always  to  be  held  in  strictest  remembrance  when  exhibiting 
the  agent. 

In  oral  surgery,  where  it  is  desirable  to  produce  the  profoundest 
and  most  prolonged  primary  impression,  chloroform,  if  it  were 
without  danger,  is  the  anaesthetic  most  indicated  and  required.  In- 
deed, in  my  own  practice  I  find  many  cases  where  I  do  not  seem 
to  be  able  to  get  along  without  it,  either  using  it  alone  or  in  asso- 
ciation with  the  ether.  Because  its  use  is  therefore  so  frequently 
necessary,  the  oral  surgeon  should  make  himself  as  familiar  as  pos- 
sible with  all  that  concerns  its  defects  as  well  as  its  virtues. 

Experiments  have  demonstrated  that  eighteen  minims  of  chloro- 
form is  the  average  quantity  necessary  to  put  an  adult  in  a  con- 
dition insensible  to  surgical  operations, — that  is  to  say,  that  this 
amount  should  be  absorbed  and  carried  to  the  nerve  centers. 

It  has  also  been  shown  "  that  chloroform  vapor  has  the  effect  of 
suddenly  arresting  the  action  of  the  heart,  when  it  is  mixed  with  the 
respired  air  to  the  extent  of  eight  or  ten  per  cent,  or  upward."   With 


254  ORAL  DISEASES  AND  SURGERY. 

these  two  lessons  appreciated,  it  is  seen  that  the  manner  and  char- 
acter of  the  exhibition  of  the  agent  have  much  to  do  with  the  result. 
Not  everything,  however,  as  it  is  too  truly  a  fact  that  fatal  acci- 
dents have  occurred  in  the  best  and  most  skillful  of  hands,  although 
in  these  latter  cases,  the  inference  is  to  be  drawn  that  the  deaths 
occurred  from  idiosyncrasies. 

Eighteen  minims,  according  to  Dr.  Snow,  are  to  be  absorbed  from 
thirty-six  breathed;  allowing  thus  that  one-half  is  lost  in  expira- 
tion. But  temperature,  as  in  the  case  of  the  ether,  has  much  to  do 
with  the  taking  up  of  such  a  quantity.  The  following  table  com- 
prises the  experiments  of  Dr.  Snow  in  this  direction.  At  a  tempera- 
ture of  40°  Fahrenheit,  100  cubic  inches  of  air  will  take  up  but  seven 
cubic  inches  of  the  vapor. 

At  45°  8  cubic  inches,  At  70°  24  cubic  inches. 

50  9           "  75  29 

65  11           "  80  36 

60  14           "  85  44 

65  19          "  90  55 

This  table  readily  exhibits  the  fact  that  anassthesia,  by  the  use  of 
chloroform,  must  come  on  at  varying  periods,  and  that  therefore  no 
judgment  of  its  proper  exhibition  is  to  be  derived  in  this  direction. 
Again,  outside  of  these  atmospheric  associations,  the  manner  of 
the  exhibition  would  have  much  to  do  with  the  minims  inspired : 
where,  for  example,  it  is  exhibited  poured  over  a  single  layer  of 
linen  (as  upon  a  handkerchief  laid  over  the  face),  quite  as  much 
would  be  lost  in  the  surrounding  atmosphere  as  would  be  inhaled 
into  the  lungs. 

Considering  the  danger  as  arising  from  the  direction  of  cardiac 
syncope,  advantage  is  to  be  taken  of  all  conditions  antagonistic  to 
such  depression.  In  blood-letting,  it  is  known  that  such  a  condition 
is  much  the  most  readily  brought  about  when  the  operation  is  per- 
formed on  the  patient  standing,  and  when  the  primary  impression 
is  made  most  marked  through  a  large  exit  for  the  blood.  In  states 
of  depression,  arising  from  whatever  cause,  either  of  physical  or 
mental  disturbance,  such  tendency  is  increased.  A  surgeon  always 
hesitates  to  bleed  a  depressed  patient ;  or,  if  such  bleeding  seems  a 
necessity,  supporting  means  are  employed  and  continued  in  con- 
junction with  the  blood-letting.  Advantage  is  taken  also  of  all  col- 
lateral indications,  as  for  example,  position,  the  patient  lying  down, 
the  head  perhaps  being  placed  on  a  lower  plane  than  the  body,  the 


GENERAL  ANAESTHESIA.  255 

orifice  of  exit  being  made  very  small ;  intermissions  in  the  flow  of 
the  blood,  stimulants,  as  the  pre-exhibition  of  brandy  or  wine, 
kind  and  encom-aging  assurances,  etc.  The  depressing  effect  of  fear 
on  the  heart's  action  is  never  to  be  lost  sight  of  in  the  administration 
of  chloroform.  How  many  patients  faint  even  while  preliminary 
arrangements  in  anticipation  of  an  operation  are  going  forward ;  and, 
indeed,  how  many  are  the  cases  on  record  of  death  from  such  fright! 
It  would  seem,  then,  that  one  would  never  be  justified  in  adminis- 
tering chloroform  to  a  patient  laboring  under  any  marked  depression, 
at  least  such  is  my  own  conviction,  and  upon  such  conviction  I  have 
always  acted.  All  persons,  or  nearly  all,  approach  an  operation 
with  a  certain  amount  of  trepidation,  but  such  fear  may,  in  the  ma- 
jority of  cases,  be  dispersed;  or  if  this  is  impossible,  then  a  prelimi- 
nary artificial  courage  maybe  given  by  the  use  of  brandy,  or  cerebral 
consciousness  may  be  disturbed  by  the  inhalation  of  a  few  drachms 
of  ether. 

The  objection,  that  chloroform  should  not  be  administered  to  a 
patient  in  a  sitting  position,  does  not,  however,  seem  to  hold  entirely 
good.  In  oral  surgery  this  is  nearly  always  the  necessary  position-; 
and  I  have  thus  administered  it,  in  perhaps  hundreds  of  cases,  with- 
out ever  having  had  any  ill  result.  A  difference  in  the  character  of 
cardiac  syncope  is  here  to  be  recognized.  The  paralysis  may  arise  from 
two  sources,  and  exhibit,  as  far  as  the  state  of  the  heart  is  concerned, 
quite  different  appearances, — that  is,  there  is  a  syncope  of  anaemia 
and  a  syncope  of  narcotism.  Now  while  there  are  between  these  two 
conditions  much  relationship,  as  the  question  of  a  vital  propulsive 
force  is  concerned,  yet  there  are  as  well  certain  differences,  of  which, 
as  surgeons,  we  may  take  advantage.  Paralysis  of  the  heart  occurs 
when,  from  any  reason,  the  organ  is  deprived  of  the  effect  of  its  natural 
stimulus,  the  blood :  this  is  the  syncope  or  paralysis  of  ansemia.  It 
occurs  again  when,  through  the  action  of  a  common  or  specific 
narcotic,  its  muscular  fibers  are  relaxed  and  deadened.  The  two 
causes  may  exist,  and  may  act  in  conjunction.  Chloroform  is  a  specific 
narcotic,  as  the  heart  is  concerned ;  at  least  this  would  seem  to  be 
the  deduction  from  post-mortems  made  in  the  fatal  cases  of  its  ex- 
hibition. In  ansemia,  syncope  is  partly  a  mechanical  production ; 
the  patient,  in  a  standing  position,  faints,  as  the  result  of  gravity 
counterbalancing  the  natural  distribution  of  the  blood.  In  narcotic 
syncope  position  is,  perhaps,  of  little  consequence,  as  far  at  least  as 
the  action  of  the  producing  cause  is,  of  itself,  concerned.  The  ques- 
tion then  of  sitting  or  lying,  as  the  exhibition  is  concerned,  resolves 


256  ORAL  DISEASES  A^W  SURGERY. 

itself  into  a  consideration  of  the  state  of  the  general  health  of  a 
patient :  if  there  is  deficiency,  either  in  quality  or  amount  of  the 
vital  fluid,  then  the  erect,  or  even  semi-erect  position,  should  never 
obtain.  If,  on  the  contrary,  a  patient  does  not  present  such  condi- 
tions, then  it  would  seem  there  is  no  special  danger  in  such  position. 

Prefatory  stimulation,  if  not  contraindicated,  is  happily  employed, 
in  conjunction  with  chloroform.  A  tablespoonful  or  more  of  brandy 
given  to  a  patient  some  five  or  ten  minutes  before  the  exhibition  of 
chloroform,  will  frequently  support  the  natural  action  of  the  heart 
through  a  prolonged  operation,  and  thus  dismiss  the  common  source 
of  alarm. 

In  my  own  practice  I  never  use  chloroform  but  in  conjunction 
with  ether — not  mixing  them,  as  in  the  common  chloric  ether,  but 
alternating,  as  the  case  seems  to  require  or  allow.  Thus,  employing 
the  cone  of  sponge,  I  commence  the  process  by  pouring  within  it  a 
quantity  of  ether,  which  is  gradually,  and  yet  as  rapidly  as  possible, 
brought  to  cover  the  mouth  and  nostrils.  If  now  I  find  the  pulse 
rapidly  increasing,  or  even  remaining  fixed  and  steady,  and  particu- 
larly if  undue  cerebral  excitability  manifests  itself,  I  drop  into  the 
cone  ten  or  twenty  drops  of  chloroform ;  this  will  generally  be  found 
to  almost  instantly  quiet  the  patient — from  this  point  I  proceed, 
using  principally  the  chloroform  or  ether,  according  to  the  result  to 
be  secured.  If  an  operation  is  one  of  simple  character  and  of  quick 
performance,  as  the  extraction  of  teeth,  or  the  making  of  some 
simple  puncture  or  incision,  then  I  think  we  had  better  not  risk 
anything  with  chloroform.  If,  on  the  contrary,  it  is  some  difficult  and 
tedious  case  about  the  mouth,  where,  after  commencing,  the  surgeon 
cannot  well  stop  to  readminister  the  anassthetic,  then  I  take  the  risk 
of  the  excess  of  chloroform  for  the  prolonged  effect  it  yields  and 
the  greater  profundity  of  the  impression  it  secures. 

The  manner  of  the  exhibition  of  the  agent  would  have,  as  one 
would  infer,  much  influence,  as  the  result  is  concerned.  Thus,  of 
the  various  apparatus  that  have  from  time  to  time  been  devised 
to  assist  in  the  use  of  chloroform,  many  are  deserving  of  no  better 
name  than  life-traps;  and  in  this  connection  one  naturally  finds 
himself  wondering  at  the  character  of  contrivances  which,  par- 
ticularly in  the  earlier  history  of  chloroform,  were  employed,  even 
by  the  ablest  men,  in  experiments  directed  to  the  testing  of  the 
general  safety  and  results  of  the  agent.  I  can  never  read  of  the 
white  mice,  and  of  the  guinea-pigs,  and  cats,  and  bell-jars  of  these 
experiments,  without  wondering  that  it  should  never  have  seemed 


GENERAL   ANESTHESIA.  257 

to  strike  them  that  animals  might  as  well  die  from  lack  of  proper 
respirable  air  as  from  chloroform. 

In  using  pure  chloroform,  it  is  most  desirable  that  there  should 
be  the  fullest  admixture  with  air ;  with  this  intention  we  use  the 
sponge,  first  softening  it  with  warm  water,  which  water  is  to  be 
well  squeezed  away.  The  respiration  should  be  easy  and  natural, 
and  the  patient  fully  en  rapport  with  the  operator.  He  should  be 
given  to  understand  that  anaesthesia  is  but  a  gentle  and  harmless 
sleep,  and  that  one  should  enter  upon  such  a  condition  as  he  enters 
upon  natural  slumber ;  if  such  confidence  can  be  secured,  there  will 
not  be  found  much  trouble  in  producing  narcotism.  Another  plan 
of  using  the  agent,  and  which  has  many  advocates,  is  to  let  fall 
drop  after  drop  upon  a  napkin,  laid  loosely  over  the  air-passages. 

However  employed,  the  principal  indication  is  to  have  it  in  proper 
dilution  and  combination  with  atmospheric  air;  this  secured,  any 
mode  of  inhalation  must  be  a  proper  one.  Insensibility,  as  re- 
marked by  Dr.  Snow,  is  not  caused  so  much  by  giving  a  dose  as  by 
performing  a  process.  Nature,  continues  this  gentleman,  supplies 
but  one  mixture  of  diluted  oxygen,  from  which  each  creature  draws 
as  much  as  it  requires ;  and  so,  in  causing  narcotism  by  inhalation, 
if  a  proper  mixture  of  vapor  and  air  is  supplied,  each  patient  will 
gradually  inhale  the  requisite  quantity  of  the  former  to  cause  in- 
sensibility, according  to  his  size  and  strength.  It  is  desirable  to 
vary  the  proportions  of  vapor  and  air,  but  rather  according  to  the 
purpose  one  has  in  view,  whether  medicinal,  obstetric,  or  surgical, 
than  on  account  of  the  age  or  strength  of  the  patient ;  for  the  respira- 
tory process  bears  such  a  relation  to  the  latter  circumstances  as  to 
cause  each  person  to  draw  his  own  proper  dose  from  a  similar  at- 
mosphere in  a  suitable  time. 

The  induction  of  insensibility  varies  with  the  individual,  or 
rather,  one  might  better  say,  with  classes  of  individuals.  One  class 
will  breathe  quietly  and  slowly,  until  unconsciousness  supervenes 
as  if  by  a  natural  sleep  ;  this  belongs  to  the  lymphatic  temperament. 
The  nervo-sanguine  or  bilious  class  are  apt  to  become  restive  and 
frightened,  and  require  a  great  amount  of  care  and  attention,  being 
the  most  difficult  to  impress.  The  true  and  full  nervous  class,  while 
timid  and  frightened,  are  apt  to  be  impressed  by  a  very  few  inhala- 
tions. There  is  one  question  that  here  arises  in  regard  to  the  exhi- 
bition of  timidity.  When  a  patient  becomes  restive  and  excited, 
shall  the  chloroformization  go  on  ?  Yes,  I  would  answer,  if  such 
exhibition  is  associated  with  mental  disturbance  produced  by  the 

17 


258  ORAL  DISEASES  AND  SURGERY. 

chloroform,  for  here  it  is  not  as  the  condition  previously  named,  but 
is  rather  an  hallucination.  These  patients  should  be  forced  rapidly 
beyond  such  states  of  excitement,  and  here  is  the  point  in  which  the 
production  of  anaesthesia  demands  the  greatest  skill,  courage,  and 
jud"-meut.  I  have  over  and  again  seen  incompetent  operators  worry 
a  poor  creature  into  a  most  wretched  condition  simply  by  fearing  to 
pass  the  Rubicon  of  excitement.  If  assured  that  all  is  right,  and 
such  assurance  is  to  be  derived  from  the  general  aspect  of  the  pa- 
tient rather  than  from  any  special  signs,  we  are  to  get  over  this  in- 
termediate excitable  stage  as  quickly  as  possible,  and  get  over  it  by 
concentrating  the  chloroform.  Patients  laboring  under  this  excita- 
bility will,  often  enough,  assure  you  that  they  feel  that  another  inha- 
lation will  kill  them  ;  that  it  is  impossible  to  breathe ;  that  the  heart 
is  laboring  under  a  wonderful  depression,  and  many  complaints  of 
like  character.  Such  speeches  are  mostly  to  be  taken  cum  grano 
salis, — the  surgeon  must  judge  for  himself. 

Before  an  operation  of  any  magnitude  is  commenced,  it  becomes 
the  surgeon  to  assure  himself  that  his  patient  is  in  the  proper  anaes- 
thetic condition.  Entire  paralysis  of  the  muscles  of  animal  life  is 
commonly  received  as  indicative  of  such  a  state, — this  being  mani- 
fested in  the  lifeless  falling  of  an  arm  when  raised.  But  this  is  not 
strictly  reliable,  as  to  obtund  sensation  we  are  aware  the  posterior 
root  of  the  spinal  cord  is  to  be  affected,  while  loss  of  motion  implies 
only  the  anaesthesia  of  the  anterior  root.  So  c|uickly,  however,  does 
the  action  of  the  agent  pass  from  the  one  to  the  other,  that  this  sign 
is  found  to  be  one  most  convenient  of  acceptance.  Dr.  Snow,  so  far 
as  I  am  aware,  was  the  first  to  call  attention  to  indications  as  af- 
forded by  the  eyelashes ;  this  test  I  have  depended  on  for  years,  and 
mostly  find  reliable.  Just  after  unconsciousness  is  induced,  remarks 
this  observer,  the  eyelashes  are  often  closed  very  strongly  when  their 
margins  are  touched,  especially  in  females,  and  there  seems  to  be  a 
positive  hyperesthesia ;  this,  however,  is  only  apparent,  and  arises 
from  the  control  of  the  will  being  removed  while  sensibility  remains. 
By  continuing  the  chloroform  the  sensibility  of  the  edges  of  the  eye- 
lids diminishes,  until,  at  last,  they  may  be  touched  without  causing 
winking.  Under  these  circumstances,  the  most  severe  operation  may, 
in  almost  every  case,  be  commenced  without  pain.  Upon  this  indica- 
tion of  the  eyelids,  Dr.  Snow  thinks  we  may  so  entirely  depend,  as 
ordinary  cases  are  concerned,  as  to  accept  from  them  information  as 
to  the  exact  extent  of  anaesthesia  existing.  When,  for  instance,  he 
says,  touching  the  margins  of  the  lids  causes  very  slight  and  Ian- 


GENERAL   ANESTHESIA.  259 

guid  winking,  the  patient  will  commonly  flinch  a  little  if  the  knife  is 
used,  but  only  in  a  manner  that  can  be  easily  restrained,  and  will 
not  interfere  with  the  majority  of  operations. 

Three  degrees  of  narcotism  are  described.  "  The  first  degree  in- 
cludes all  the  eflFects  of  chloroform  that  exist  while  a  patient  retains 
a  perfect  consciousness  of  where  he  is  and  what  is  occurring.  In 
the  second  degree  there  is  no  longer  correct  consciousness.  The 
mental  functions  are  impaired,  but  not  necessarily  suspended.  In 
the  third  degree  there  are  no  longer  any  voluntary  motions." 

The  circumstances  which  influence  or  modify  the  effects  of  chloro- 
form are  thus  considered  by  Dr.  Snow,  than  whom,  perhaps,  there 
is  no  one  whose  observations  have  been  of  a  more  extended  or 
thorough  nature  ;  although  it  is  not  to  be  overlooked  that  he  was  so 
sanguine  in  this  direction  that  perhaps,  in  some  instances  at  least, 
his  prejudices  may  have  influenced  somewhat  his  judgment. 

"  I  arrived  at  the  conclusion,"  says  he,  "  after  much  careful  obser- 
vation, that  chloroform  might  be  given  with  safety  and  advantage 
in  every  case  in  which  the  patient  requires,  and  is  in  a  condition  to 
undergo,  a  surgical  operation.  And  having  acted  on  this  conclusion 
for  several  years,  I  have  found  no  reason  to  change  it.  It  is  desir- 
able, however,  to  pay  attention  to  every  circumstance  connected 
with  the  health  and  constitution  of  the  patient  before  exhibiting 
chloroform,  as  many  of  these  circumstances  influence  its  effects." 

Age. — "  The  age  of  a  patient  has  considerable  influence  in  modi- 
fying the  effects  of  chloroform.  It  acts  very  favorably  on  children. 
They  sometimes  oppose  the  inhalation  of  it  as  long  as  they  are  con- 
scious, but  it  does  not  occasion  the  rigidity  and  struggling,  after  loss 
of  unconsciousness,  which  are  sometimes  met  with  in  the  adult. 
Anaesthesia  is  generally  induced  with  a  less  amount  of  narcotism  of 
the  nervous  centers  in  children  than  in  grown  persons. 

"  The  eff'ects  of  chloroform  are  more  quickly  produced,  and  also 
subside  more  quickly  in  children  than  in  adults,  owing,  no  doubt,  to 
the  quicker  breathing  and  circulation.  It  often  happens,  however, 
that  when  the  insensibility  has  been  kept  up  for  some  time,  say 
twenty  minutes  or  half  an  hour,  in  a  child,  it  is  followed  by  a  natu- 
ral sleep  of  a  few  hours'  duration,  provided  there  is  no  painful 
wound  or  other  cause  to  prevent  the  sleep.  I  have  given  chloroform, 
in  a  few  cases,  as  early  as  the  age  of  eight  or  ten  days,  and  in  a  con- 
siderable number  of  cases  before  the  age  of  two  months.  And  I 
own  memoranda  of  hundreds  of  cases  under  a  year  old  to  whom  I 
have  administered  this  agent.     There  has  been  no  ill  effect  from  it 


260  ORAL  DISEASES  AND  SURGERY. 

either  in  these  cases  or  in  those  of  children  more  advanced  in  life ; 
and  it  is  worthy  of  remark,  that  none  of  the  accidents  from  chloro- 
form which  have  been  recorded  have  occm'red  to  young  children."    | 

There  is  nothing  peculiar  in  the  effect  of  chloroform  upon  people! 
advanced  in  years  except  that  its  influence  subsides  rather  slowly' 
on  account  of  the  slower  breathing  and  circulation.  I  have  given ' 
chloroform  to  many  patients  over  seventy-five  years  of  age,  and  to ! 
one  as  old  as  ninety  years.  , 

Strength  or  Debility. — "The  comparative  strength  or  debility j 
of  the  patient  has  considerable  influence  on  the  way  in  which  chloro-i 
form  acts.     Usually  the  more  feeble  the  patient  is,  whether  from  ill-i 
ness  or  any  other  cause,  the  more  quietly  does  he  become  insensible ;  j 
while  if  he  is  strong  and  robust,  there  is  very  likely  to  be  mental ' 
excitement  in  the  second  degree,  and  rigidity  of  the  muscles,  and 
})robably  struggling  in  the  third  degree  of  narcotism.     Patients  in 
a  state  of  debility  resemble  children,  not  only  in  coming  quietly  and 
easily  under  the  influence  of  chloroform,  but  also  in  the  circumstance, 
that  the  common  sensibility  is  suspended  with  less  narcotism  of  the 
nervous  centers  than  is  generally  required  in  robust  persons.     Chil- 
dren, and  persons  in  a  state  of  debility,  have  usually  an  acute  sen- 
sibility, which  causes  them  to  suffer  pain  from  very  slight  injuries, 
but  this  sensibility  is  more  easily  suspended  by  chloroform  than  the 
less  acute  sensibility  of  robust  persons." 

Hysteria. — "  Patients  who  are  subject  to  hysteria  sometimes 
have  symptoms  of  the  complaint,  such  as  sobbing,  crying,  or  laugh- 
ing, as  soon  as  consciousness  is  suspended,  or  even  impaired,  by  the 
chloroform;  but  these  symptoms  can  always  be  subdued  by  pro- 
ceeding with  the  inhalation.* 

"  In  some  persons  who  are  subject  to  hysteria  the  breathing  be- 
comes excessively  deep  and  rapid  while  inhaling  chloroform. f    This 

*  Chloroform  in  hysteria  is,  I  think,  one  of  the  most  valuable  medicines  of 
the  Materia  Medica,  while,  on  the  contrary,  sulphuric  ether  is,  so  far  as  my 
experience  goes,  most  decidedly  objectionable  to  such  patients.  I  have  treated 
females  atHicted  in  this  way  where  ether  had  been  used  by  the  pound  with  no 
other  efiect  seemingly  than  increasing,  intensifying,  and  prolonging  the  par- 
oxysm ;  yet  with  a  very  few  inhalations  of  chloroform,  I  have  had  the  pleas- 
ure of  seeing  these  persons  fall  into  the  most  natural  slumber,  and  after  rest- 
ing quietly  for  hours,  the  slumber  prolonged,  perhaps,  as  sometimes  has  seemed 
indicated,  by  occasional  repetition  of  the  inhalation,  I  have  seen  them,  over 
and  again,  awake  perfectly  recovered. 

t  Dr.  Snow,  in  his  paragraph,  remarks  the  supervening  of  this  condition 
after  the  first  few  inhalations,  but,  according  to  my  own  experience,  it  is  as 


GENERAL  ANESTHESIA.  261 

usually  occurs  just  as  the  patient  is  becoming  unconscious,  but  in  a 
few  cases  even  earlier,  and  the  patient  is  aware  of  the  impulse  to 
breathe  in  this  manner.  After  this  kind  of  hysterical  breathing  has 
lasted  a  minute,  the  patient  generally  rests  nearly  a  minute  without 
breathing  at  all,  after  which  the  respiration  becomes  generally  very 
natural.  Chloroform  is  to  be  given  very  sparingly  during  the  vio- 
lent breathing,  or  else  withdrawn  altogether  for  a  minute  or  two." 

Pregnancy. — It  is  not  generally  esteemed  that  there  is  anything 
in  this  condition  objectionable  to  the  use  of  chloroform. 

The  Menstrual  Period. — This  period  is  certainly  not  to  be  pre- 
ferred or  selected  as  an  occasion  of  chloroform  exhibition.  Yet  is 
there  nothing  at  all  in  the  condition  adverse  to  such  exhibition. 
The  controlling  effect  of  the  agent  over  hysterical  symptoms  has  just 
been  remarked,  and  such  irritability  of  the  system  is  the  only  pecu- 
liarity of  this  state.  Indeed,  it  is  very  common  that  the  hysterically 
inclined  female  is  compelled  to  resort  to  chloroform,  particularly  in 
conditions  of  dysmenorrhoea. 

Diseases  of  the  Lungs. — "Affections  of  the  lungs  sometimes 
cause  a  little  difficulty  and  delay  in  the  administration  of  chloroform, 
as  the  vapor  is  liable  to  excite  coughing  when  the  mucous  membrane 
of  the  air-passages  is  irritable.  The  inconvenience  is,  however,  con- 
fined to  the  time  of  inhalation,  for  the  cough  is  generally  relieved 
afterward.* 

"I  have  given,"  says  Dr.  Snow,  "  chloroform  for  surgical  purposes 
in  many  cases  where  phthisis  was  present,  and  in  several  patients 
who  had  suffered  from  haemoptysis,  and  have  not  seen  any  ill  effects 
from  its  use  in  these  cases.  Chloroform  has,  indeed,  often  been  in- 
haled with  advantage  to  relieve  the  cough  in  consumption.  The 
cases  of  chronic  bronchitis  in  which  chloroform  is  administered  and 
for  surgical  operations  ai"e  still  more  numerous." 

Disease  of  the  Heart. — "There  is  a  very  general  impression 
that  the  use  of  chloroform  is  unsafe  when  disease  of  the   heart 


uncommon  when  chloroform  is  used  as  it  is  common  in  the  employment  of 
ether.  When,  in  administering  ether,  I  see  the  slightest  signs  of  hysteria, 
either  in  male  or  female,  I  always  expect  at  once  to  control  them  by  replacing 
the  ether  with  chloroform. 

*  This  difficulty,  as  observed  not  only  by  Dr.  Snow,  but  alluded  to  by 
nearly  all  writers  on  anaesthesia,  I  have  found  to  be  almost,  if  indeed  not  en- 
tirely, obviated  by  preceding  the  exhibition  with  a  tablespoonful  of  thick 
mucilage  of  gum  acacia,  the  patient  allowing  it  gradually  to  lose  itself  over 
the  mucous  surfaces. 


262  ORAL  DISEASES  AND  SURGERY. 

exists,  more  particularly  fatty  degeneration  of  that  organ.  This 
belief  has  been  encouraged  by  the  circumstance  that  this  affection  ; 
has  been  present  in  a  few  of  both  the  real  and  alleged  deaths  from  t 
chloroform,  and  also  by  the  fact  that,  in  the  accidents  that  have  been 
really  due  to  chloroform,  the  heart  has  been  the  organ  on  which  it 
has  exerted  its  fatal  influence.  When  we  come  to  investigate  these 
eases  however,  we  shall  find  reason  to  conclude  that  the  heart  has 
probably  been  diseased  in  quite  as  great  a  proportion  of  the  patients  i 
who  have  taken  chloroform  without  ill  effects  as  those  who  have  \ 
succumbed  under  its  influence.  As  regards  my  own  practice,"  says 
this  authority,  "the  only  case  in  which  death  could  in  any  degree  be 
attributed  to  the  chloroform,  was  one  in  which  there  was  extreme 
fatty  degeneration  of  the  heart ;  but,  on  the  other  hand,  I  have 
o-iven  chloroform  in  numerous  cases  without  ill  effect  where  the 
symptoms  of  this,  as  well  as  of  other  affections  of  the  heart,  were 
present  in  a  marked  degree.  Indeed,  I  have  never  declined  to  give 
chloroform  to  a  patient  requiring  a  surgical  operation,  whatever 
might  be  his  condition,  as  I  early  arrived  at  the  conclusion  that  this 
agent,  when  carefully  administered,  causes  less  disturbance  of  the 
heart  and  circulation  than  does  severe  pain.  Wherever,"  continues 
Dr.  Snow,  "  I  have  had  an  opportunity  of  seeing  an  operation  per- 
formed without  chloroform,  I  have  carefully  examined  the  pulse, 
and  although  none  of  these  operations  have  been  of  a  very  severe 
nature,  I  have  found  the  circulation  to  be  much  more  disturbed  than 
it  would  have  been  by  chloroform  carefully  administered.  The  pulse, 
in  most  of  these  cases,  has  been  exceedingly  frequent  during  the 
operation,  and  in  some  instances  it  has  intermitted  to  an  unusual 
extent. 

"In  one  instance  I  had  an  opportunity  of  witnessing  a  similar 
operation  on  the  same  patient,  first  without  chloroform,  and  after- 
ward under  the  influence  of  the  agent.  In  the  operation,  which  was 
lithotrity,  at  the  first  operation  I  began  to  feel  the  pulse  just  when 
the  patient  saw  the  lithotrite  about  to  be  introduced.  It  was  120  in 
the  minute.  As  soon  as  the  instrument  was  introduced  the  pulse 
increased  to  144,  and  immediately  afterward  it  became  uneven,  irreg- 
ular, and  intermitting.  I  could  not  count  more  than  three  or  four 
beats  at  a  time ;  and,  occasionally,  when  the  pain  seemed  greatest, 
and  the  man  was  straining  and  holding  his  breath,  the  pulse  was 
altogether  absent  for  four  or  five  seconds.  In  order  to  ascertain 
whether  the  absence  of  the  pulse  at  the  wrist  might  not  depend  on 
the  pressure  of  the  muscles  of  the  arms,  caused  by  grasping  the 


GENERAL   ANESTHESIA.  263 

table,  I  applied  my  ear  to  the  chest,  and  found  that  there  was  no 
sound  whatever  to  be  heard  during  the  intervals  when  the  pulse  was 
imperceptible.  It  was  evident  that  the  patient  held  his  breath  till 
the  right  cavities  of  the  heart  became  so  distended  as  to  stop 
the  action  of  the  organ  till  the  respiration  returned.  The  man  did 
not  complain  or  cry  out  during  the  operation. 

"A  week  afterward  the  lithotrity  was  repeated,  but  on  this  occa- 
sion I  administered  chloroform.  The  pulse  was  120  in  the  minute 
when  the  patient  began  to  inhale  the  chloroform,  but  it  became 
slower  as  he  was  made  unconscious,  and  it  was  regular  during  the 
operation.  It  was  only  toward  the  end  of  the  operation,  when  the 
effect  of  the  agent  was  allowed  to  diminish,  and  when  the  man 
began  to  strain  a  little,  though  not  yet  conscious,  that  the  pulse  in- 
termitted slightly,  passing  over  a  single  beat  occasionally.  There 
were  none  of  the  long  intermissions  of  the  pulse  observed  on  the 
former  occasion. 

"It  is  very  evident  that  if  the  above-mentioned  patient  had  been 
the  subject  of  any  affection  of  the  heart  which  weakened  or  embar- 
rassed its  action,  he  would  have  run  a  much  greater  risk  from  the 
pain  of  the  first  operation  than  from  the  inhalation  of  the  chloroform 
in  the  second  one. 

"  In  a  few  of  the  patients  having  the  arcus  senilis  of  the  cornea, 
a  weak,  intermitting,  or  irregular  pulse,  and  other  signs  of  fatty 
degeneration  of  the  heart,  there  have  been  a  feeling  of  faintness  and 
a  tendency  to  syncope  as  the  effects  of  the  chloroform  were  sub- 
siding, especially  when  the  operation  had  been  performed  in  the  sit- 
ting position ;  but  these  symptoms  have  soon  subsided,  in  all  cases 
I  have  met  with,  on  placing  the  patient  horizontally,  with,  or  with- 
out, the  help  of  a  little  ammonia  to  the  nostrils." 

Cerebral  Diseases. — "Affections  of  the  head  offer  no  obstacle 
to  the  administration  of  chloroform.  I  have  given  it  to  several 
patients  who  had  suffered  previously  from  an  attack  of  apoplexy; 
some  of  them  still  retained  the  paralysis  resulting  from  the  attack, 
but  the  chloroform  has  not  been  attended  or  followed  by  ill  effects 
in  any  of  these  cases." 

The  following  interesting  and  most  instructive  case  is  mentioned 
in  this  direction. 

"  The  31st  of  October  was  a  day  appointed  by  Mr.  Fergusson  to 
perform  lithotrity  on  a  gentleman  seventy-eight  years  of  age,  who 
had  a  phosphatic  calculus  in  his  bladder.  He  was  a  patient  of  Mr. 
Propert,  and  Mr.  Fergusson  had  removed  a  similar  calculus  by  litho- 


2(34  ORAL  DISEASES  AND   SURGERY. 

trity,  and  I  Lad  given  him  chloroform  at  each  of  the  operations,  and 
it  was  arran"-cd  that  he  should  have  chloroform  on  the  present  occa- 
sion. Mr.  Propert  informed  Mr.  Fergusson  and  myself  on  our  arrival 
that  his  patient  had,  the  night  before,  an  attack  resembling  apoplexy; 
he  had  been  insensible  ;  the  breathing  had  been  stertorous,  the  pupils 
dilated,  and  the  face  very  red  and  congested.  Mr.  Propert  had 
caused  him  to  be  cupped  to  fourteen  ounces,  and  had  given  him 
twenty  grains  of  calomel  in  the  course  of  the  night,  and  in  the 
morning  he  was  as  usual,  and  remained  so  at  the  time  of  our  visit. 
We  considered  the  case  with  Mr.  Propert,  and  as  there  were  reasons 
for  not  postponing  the  operation,  it  was  determined  that  he  should 
inhale  the  chloroform  rather  than  be  subjected  to  the  pain.  The 
vapor  acted  very  favorably,  he  recovered  his  consciousness  a 
few  minutes  after  the  operation,  and  expressed  himself  as  feeling 
quite  well." 

Insanity. — Chloroform  acts  on  insane  patients  just  as  it  does  on 
others :  when  the  effects  subside  they  are  in  the  same  state  of  mind 
as  before.  Mr.  Snow  remarks  the  suspiciousness  of  the  insane,  but 
gives  his  experience  where  teeth  have  been  extracted  and  other 
operations  performed  which  it  w^ould  have  been  impossible  to  ac- 
complish in  the  same  individual  without  resorting  to  inhalation. 
The  employment  of  chloroform  in  the  delirium  of  mania  a  potu  has, 
through  the  experiments  of  Dr.  Ely  McClellan,  of  the  United  States 
Army,  lately  been  revived,  and  commanded  much  attention,  the  suc- 
cesses of  this  gentleman  having  been  quite  sufficiently  verified  by 
practitioners  in  every  part  of  the  country :  given  in  drachm  doses, 
jyt'o  re  nata,  it  seems  completely  to  break  the  paroxysm,  causing 
the  patient  to  fall  into  profound  sleep,  from  which,  after  eight  or 
ten  hours,  he  commonly  awakes  entirely  relieved.  In  delirium, 
however,  the  chloroform  is  to  be  taken  into  the  stomach,  and  not 
breathed. 

I  may  close  this  consideration  of  chloroform  by  again  remarking, 
as  alluded  to  in  the  commencement  of  the  chapter,  that  the  agent, 
if  one  feels  justified  in  using  it,  is  far  to  be  preferred  in  oral  surgery 
to  the  ether — a  profound  impression  created  through  chloroform  will 
not  unfrequently  continue  through  quite  a  prolonged  operation ;  or 
if  it  be  necessary  to  renew  the  inhalation,  the  desired  impression 
is  generally  made  with  great  rapidity.  Operations  about  the  mouth, 
unlike  most  other  surgical  services,  require  to  be  executed  with 
great  rapidity;  therefore  is  it  a  necessity  to  be  as  little  interfered 
with  as  possible:  an  impression,  apparently  very  profound,  made 


GENERAL  ANESTHESIA.  265 

with  ether,  is  apt  to  be  broken  in  the  very  first  shock  of  an  oral 
operation.  This  first  step  may  be  of  a  character,  starting,  in  some 
instances,  frightful  hemorrhage,  and  which  can  only  be  combated 
at  the  completion  of  the  operation ;  to  have  a  patient  start  from  con- 
trol at  such  a  moment,  and  under  such  circumstances,  is  sometimes 
a  matter  of  serious  concern.  If  one  has  not  used  chloroform  up  to 
this  time,  and  the  article  is  at  all  convenient,  it  is  very  apt  to  be 
given  to  the  patient  in  a  quite  free  manner.  I  certainly  do  desire 
heartily  to  recommend  it,  but  prefer,  as  my  own  practice  is  con- 
cerned, to  combine  it  in  varying  proportions  with  sulphuric  ether. 
I  have,  in  this  chapter,  used,  in  many  instances,  the  strong  authori- 
tative experiences  of  Dr.  Snow.  I  believe,  and  think  I  know  for  truth, 
all  that  he  maintains ;  his  experience  with  the  agent  has  certainly 
been  of  the  most  extensive  nature,  yet  personally,  however,  I  am 
as  yet  afraid  to  use  chloroform  but  in  conjunction  with  ether ;  and 
while  such  fear  may  not  at  all  be  well  grounded,  yet  as  it  exists,  I 
cannot  do  otherwise  than  give  expression  to  it.  At  this  day  it  is 
certainly  idle  enough  to  attempt  to  deny  that  many  deaths  have 
occurred  in  the  use  of  chloroform,  and  these  accidents  have  hap- 
pened not  alone  in  the  hands  of  the  charlatan,  but  the  propor- 
tion of  accidents  have  occurred  with  most  eminent  and  skillful 
men,  and  where  every  care  and  scientific  precaution  possible  were 
taken. 

Again,  the  accidents  have  seldom  or  never  been  traceable  to  an 
overdose  of  the  agent ;  the  deaths  have  never  occurred  from  narco- 
tism, but  from  direct,  immediate,  and  unforeseeable  paralysis  of  the 
heart.  I  have  not  overlooked  the  fact,  that  fatal  results  happening 
while  chloroform  was  being  used,  might  not  be  at  all  owing  to  this 
agent.  Certainly  there  are  cases  enough  on  record  justifying  such 
a  conclusion — cases  with  which  every  surgeon  must  be  familiar 
enough;  but,  on  the  other  hand,  there  are,  as  well,  instances  in 
such  doubt,  or  perhaps  I  should  rather  say,  of  such  certainty,  that 
one  may  rather  err  on  the  side  of  discretion. 

NITKOUS  OXIDE  GAS. 

Except  as  its  use  in  dental  surgery  proper  is  concerned,  I  do  not 
think  nitrous  oxide  will  ever  be  found  applicable  to  oral  operations 
(at  least,  as  we  at  present  know  how  to  get  the  effects  of  this  agent). 
In  this  opinion,  I  am  very  well  aware,  others  may  not  feel  disposed 
to  agree  with  me,  and  it  may  very  well  be  that  I  am  wrong,  as  I 


266  ORAL  DISEASES  AND  SURGERY. 

have  had  little  experience  with  the  agent.  Be  this  as  it  may,  how- 
ever, ether  and  chloroform  appear  so  satisfactory,  and  every  way 
reliable,  and  at  the  same  time  are  so  convenient  of  use  compared 
with  the  gas,  that  I  imagine  they  will  continue  to  hold  the  supre- 
macy.* 

*  For  a  learned  and  exhaustive  treatise  on  this  subject,  see  a  work  by  Dr. 
Geo.  J.  Ziegler.  Also  an  able  monograph  by  Dr.  Geo.  T.  Barker,  published 
in  Philadelphia. 


CHAPTER    XVII. 


SALIVARY    FISTULE. 


As  a  result  of  wounds,  abscesses,  ulcers,  and  other  similar  causes, 
it  sometimes  happens  that  external  communication  is  established 
with  the  duct  of  Steno,  in  consequence  of  which  the  secretions  of 
the  parotid  gland,  instead  of  passing  into  the  oral  cavity,  subserv- 
ing their  recremental  purpose,  are  poured  out  over  the  cheek,  irri- 
tating these  parts,  and  proving  the  source  of  greatest  discomfort, 
not  unfrequently,  indeed,  locating  quite  intractable  excoriations.  In 
children,  cancrum  oris  has  frequently  so  sloughed  away  portions  of 
the  cheek  as  to  produce  the  most  intractable  of  fistulas,  necessitating, 
indeed,  plastic  operations  for  their  cure. 

An  ordinaiy  fistule  is  very  well  represented  by  the  accompanying 
view. 

Fig.  57. — Salivary  Eistule — from  Life. 


In  this  particular  case,*  the  fistule  was  the  result  of  abscess 
of  the  cheek,  induced  by  caries  of  the  tuberosity  of  the  right 
superior  maxilla;    the  history  of  the  case  being  as  follows:  the 

*  Added  to  this  figure,  which  is  from  life,  is  exhibited  a  second  form,  that 
of  parotid  fistule  proper.  The  one  cut  has  been  made  to  subserve  the  two 
illustrations. 

(267) 


268  ORAL  DISEASES  AND  SURGERY. 

patient,  a  gentleman  of  most  excellent  constitution  and  easy  cir- 
cumstances, suffering  from  a  carious  wisdom  tooth,  had  sought 
relief  in  its  extraction.  The  dentist,  however,  to  the  misfortune 
of  the  patient,  broke  the  tooth,  and  was  unable  to  remove  the 
fang.  From  the  irritation  thus  induced,  conjoined  with  that  resid- 
ing in  the  broken  and  inflamed  root,  a  caries  of  the  bone  was  in- 
duced ;  this,  in  its  turn,  inflaming  the  cheek,  an  abscess  formed ; 
this  opened  externally,  involving  the  duct  of  Steno,  thus  producing 
fistule.  The  ordinary  condition  of  the  patient  was  as  follows :  the 
natural  outlet  of  the  gland  continued  patulous ;  consequently,  to  the 
comfort  of  the  case,  much  of  the  secretion  found  its  way  into  the 
mouth.  Through  the  artificial  channel  enough,  however,  escaped 
to  keep  the  cheek  constantly  bathed  with  saliva  and  pus,  the  orifice 
being  constantly  covered  with  a  large  but  soft  and  pasty  imperfect 
scab.  Of  course,  so  long  as  the  saliva  discharged  through  this 
channel,  it  was  impossible  for  nature  to  close  it. 

In  this  case,  three  weeks,  lacking  three  days,  were  required  for 
the  cure:  first,  examination  was  directed  to  the  condition  of  the 
underlying  parts.  The  caries  of  the  bone  being  found  cured,  the 
depth  and  course  of  the  fistule  was  discovered  by  the  use  of  the 
ordinary  silver  probe.  This,  for  three  days,  was  enlarged  by  the 
introduction,  each  day,  of  a  twisted  tent  of  cotton.  At  the  end  of 
this  period  a  slender,  straight-bladed  bistouiy  was  passed  directly 
through  the  cheek  into  the  mouth.  An  eyed  probe  was  next 
threaded  with  a  cotton  tent,  large  and  thick  at  the  part  which  was 
to  occupy  the  inner  half  of  the  thickness  of  the  cheek,  delicate,  and 
as  threadlike  as  it  could  be  made  where  it  was  to  be  lodged  in  the 
track  of  the  fistule.  By  the  aid  of  the  probe  this  tent  was  carried 
through  the  cheek,  and  was  then  fixed  in  position  by  a  little  slip 
of  adhesive  plaster,  attaching  it  to  the  cheek.  This  tent,  being  kept 
clean  and  disinfected  by  daily  syringing,  was  retained  in  position 
one  week,  the  swelling  of  the  inner  bulky  portion  having  by  this 
time  resulted  in  the  formation  of  quite  a  channel,  with  a  correspond- 
ing diminution  in  the  diameter  of  the  fistule.  At  this  stage  the 
cotton  was  replaced  with  a  wire  seton,  made  by  taking  the  most 
delicate  of  ligature  iron  wire,  doubling  it  upon  itself  a  number  of 
times  to  half  the  thickness  of  the  cheek,  a  single  strand  containing 
the  length  designed  to  occupy  the  line  of  the  fistule.  To  replace  the 
one  Mith  the  other  it  was  only  necessary  to  attach  them  by  an  in- 
termediate strand  of  silk:  as  one  was  withdrawn,  the  other  occu- 
pied its  place.     This  wire  seton  was  thus  inserted,  and  was  held 


SALIVARY  FISTULE.  269 

in  place  by  perforated,  shot  clamped  on  each  extremity.  In  one 
week  the  external  or  original  fistule  had  closed  so  as  to  hug  the 
wire,  the  discharge  being  entirely  into  the  mouth.  The  seton  was 
now  withdrawn  entirely,  and  on  the  next  day  complete  closure  was 
found  to  have  resulted.  The  case  was  thus  dismissed  cured,  and 
remained  so. 

A  more  common  way  to  operate  in  salivary  fistulas  is  to  take  a 
strand  of  well-waxed  ligature  silk,  threaded  at  each  end  to  straight 
or  curved  needles,  as  preferred ;  seeking  the  bottom  of  the  fistule, 
the  first  needle  is  thrust  through  the  cheek  into  the  vestibule  and 
brought  out  at  the  mouth  ;  the  second,  needle  is  now  passed  to  the 
bottom  of  the  fistule  precisely  as  the  first,  and  is  also  thrust  through 
into  the  mouth,  but  leaving  some  little  tissue  between  its  exit  and 
the  line  of  the  first.  The  two  ends  being  out  of  the  mouth,  a  single 
knot  is  made,  drawing  it  close  up  to  the  mucous  surface  of  the  cheek, 
strangulating  the  contained  tissue.  This  strangulation,  however, 
is  not  absolutely  necessary,  many  surgeons,  indeed,  preferring  the 
knot  loose,  and  to  have  the  new  passage  resultant  simply  from  the 
presence  of  the  silk.  With  such  a  new  passage,  the  original  fistule 
will  mostly  tend  to  heal  of  itself,  particularly  will  this  be  found  the 
case  where  the  passage  has  been  so  made  as  to  afford  easier  exit 
for  the  fluid  than  the  fistule.  It  is  on  such  account  that  my  own 
experience  prefers  the  operation  first  described. 

Another  form  of  salivary  fistule,  and  one  much  more  difficult  to 
treat,  is  where,  from  operations  performed  over  the  parotid  region, 
the  gland  has  been  exposed  and  some  of  its  lobules  opened.  See 
Fig.  57. 

To  treat  such  a  case,  attempt  may  first  be  made  to  close  the  opening 
by  means  of  a  cauterant,  either  the  actual  or  potential.  Of  the  latter, 
the  crystals  of  the  chloride  of  zinc  should,  I  think,  have  the  pref- 
erence, being  markedly  provocative  of  healthy  granulations.  Ni- 
trate of  silver  has  been  used  by  many  with  reported  good  success. 
Cauterization,  however,  we  are  compelled  to  admit,  is  much  more 
frequently  unsuccessful  than  otherwise,  the  more  philosophical  and 
effectual  mechanical  measures  being  required. 

A  mode  of  operation,  not  unlikely  to  meet  with  success,  consists 
in  the  use  of  the  strands  of  wire,  made  and  employed  precisely  as 
suggested  in  the  more  simple  cases. 

It  has  been  recommended  by  many  surgeons  that  in  cases  of 
fistulae  with  induration  of  the  part,  such  tissue  be  punched  or  cut 
out :  this  was  a  favorite  mode  with  the  late  Professor  Horner.     To 


270  ORAL  DISEASES  AND  SURG  ERF. 

accomplish  this  end,  a  blade  or  spatula  of  wood  is  placed  against 
the  inside  of  the  cheek,  thus  supporting  it ;  a  slight  longitudinal  in- 
cision is  now  made  on  the  outside,  through  which  the  punch  is 
passed,  cutting  the  section  from  the  inside  half  of  the  thickness ;  the 
external  wound  is  next  approximated  with  a  few  stitches  of  the  in- 
terrupted suture,  and  if  union  should  be  secured,  the  cure  will  be 
found  complete.  In  this  connection,  too  much  praise  cannot  be 
given  to  applications  of  alum-water,  alternated,  if  it  is  thought  de- 
sirable, with  very  dilute  tincture  of  capsicum.  With  these  applica- 
tions, I  am  certain  that  I  have  secured  union  in  cases  which,  with- 
out them,  would  have  been  utter  failures.  Upon  Plate  YI.,  taken 
from  Professor  Smith's  Principles  and  Practice  of  Surgery,  Figs.  1,  2, 
and  3,  the  surgical  relations  of  fistule  are  exhibited ;  also  Horner's 
operation. 


PLATE    VI. 

A  VIEW  OF   THE  ANATOMY    OF  THE    SIDE  OF  THE    FACE,  AND  OF  SOME' 
OF  THE  OPERATIONS  PRACTICED  ON  IT. 

Fig.  1.— a  side  view  of  the  Anatomy  of  the  Face  after  the  removal  of  the 
integuments.  1.  The  shape  and  position  of  the  parotid  gland.  2. 
The  duct  of  Steno.  3.  The  sublingual  gland.  4.  The  facial  artery, 
at  the  point  where  it  passes  on  to  the  face.  5.  The  facial  vein.  6. 
The  sterno-cleido-mastoid  muscle.  7.  The  external  jugular  vein. 
8.  The  zygomatic  muscle.  9.  Branches  of  the  portio  dura  nerve 
emerging  from  the  upper  edge  of  the  parotid  ;  other  branches  are 
seen  on  the  face. — AJter  Bernard  and  Huette. 

Fig.  2. — The  same  Section  after  the  removal  of  the  Parotid  Gland.  1.  The 
portio  dura  nerve  at  its  exit  from  the  stylo-mastoid  foramen.  2. 
The  duct  of  Steno  divided  transversely.  3.  The  external  carotid 
artery  when  freed  from  the  parotid.  4.  The  temporal  artery.  5. 
The  facial  artery  after  removal  of  the  sublingual  gland.  6.  The 
sterno-cleido  muscle.  7.  Main  trunk  of  the  external  jugular 
veiii. — After  Bernard  and  Huette. 

Fig.  3. — A  three-quarter  view  of  Horner's  operation  for  the  cure  of  Salivary 
Fistula.  A  wooden  spatula  supports  the  inside  of  the  cheek ;  a 
slight  longitudinal  incision  is  made  at  the  external  fistulous  orifice, 
and  the  hand  of  the  surgeon  is  seen  pressing  the  punch  against  the 
spatula  so  as  to  cut  out  a  piece  through  the  cheek.  The  external 
incision,  being  closed  by  a  point  of  a  suture,  heals  usually  by  the 
first  intention,  leaving  the  orifice,  made  by  the  punch,  open  in  the 
mouth. — Drawn  from  Nature. 

Fig.  4. — A  view  of  the  operation  of  Resection  of  the  Upper  Jaw,  as  practiced 
by  the  incision  of  Warren.  1,  2,  3.  The  flaps  everted,  and  turned 
over  the  nose  and  eye  so  as  to  expose  the  bone.  The  left  hand  of 
the  surgeon  is  holding,  4,  the  bone  at  the  moment  of  disarticu- 
lation by  the  knife,  5,  which  is  working  at  the  pterygo-m axillary 
fissure.  Velpeau's  operation  is  nearly  the  same  as  that  of  War- 
ren.— After  Bernard  and  Huette. 

Fig.  6. — Represents  the  completion  of  the  operation,  the  union  of  the  wound 
by  the  twisted  suture,  and  the  line  of  the  cicatrix,  which  extends 
from  the  malar  bone  to  the  mouth  near,  but  not  at,  the  angle. — 
After  Bernard  and  Huette. 

Fig.  6. — A  view  of  the  termination  of  Gensoul's  operation,  showing  the  lines 
of  his  incision.  1,  2.  The  first  incision  across  the  tumor.  3,  4. 
The  second  incision.  1,  5.  The  third  incision,  forming  flaps  which 
are  to  be  turned  up  and  down  upon  the  face.  The  sutures  are  seen 
as  placed  at  the  termination  of  the  operation. — After  Gensoul. 

Note. — Figs.  4,  5,  and  6  refer  to  operations  considered  in  another  connection. 

(271) 


CHAPTER    XYIII. 


THE   TONSIL   GLANDS. 


The  tonsil  glands,  situated  on  cither  side  of  the  fauces,  between 
the  half  arches,  arc  readily  exposed  by  depressing  the  tongue  through 
the  instrumentality  of  any  convenient  means.  An  instrument  made 
especially  for  the  purpose,  called  a  "depressor,"  will  be  found  very 
well  adapted. 

The  tonsils,  glandular  organs,  are  made  up  of  many  lobules,  with 
intervening  sulci  lined  by  involutions  of  the  common  mucous  mem- 
brane. Inflammation,  simple  or  acute,  and  chronic  or  morbid,  is  the 
disease  of  these  glands.  With  the  first  are  associated  the  various 
features  of  vascular  change,  passing  from  the  most  transient  of  con- 
gestions to  the  most  threatening  of  abscesses. 

Fig.  58.— The  Toxsil  Glands. 


Simple  tonsillitis — angina  tonsillaris — amygdalitis — is  an  inflam- 
mation of  the  substance  of  the  gland.  Looking  into  the  mouth,  the 
bodies,  one  or  both,  are  discovered  unduly  colored  and  swollen ;  if 
the  inflammation  is  of  any  severity  in  its  grade,  the  patient  experi- 
ences pain  and  difficulty  in  swallowing,  a  sense  of  dryness,  heat,  and 
fever  in  the  fauces ;  and  these  discomforts,  influenced  by  the  charac- 
ter of  the  attack,  may  progress  until  it  becomes  impossible  to  swal- 
low, and  in  many  cases  exceedingly  difficult  to  breathe. 
(272) 


THE    TONSIL   GLANDS.  273 

Glancing  at  the  view,  which  exhibits  the  glands  in  a  state  of  par- 
tial enlargement,  it  is  plainly  enough  seen  that  the  isthmus  would 
be  closed  in  proportion  to  such  enlargement ;  hence  the  difficulty  ex- 
perienced in  deglutition  and  respiration.  Tonsillitis  ends  either  in 
resolution  or  suppuration. 

When  the  inflammation  is  met  with  in  its  incipiency,  attempts  are 
at  once  to  be  made  to  resolve  it  by  the  use  of  antiphlogistic  remedies, 
— free  scarification  has  occasionally  been  resorted  to  with  the  best  re- 
sults. Leeches  externally,  and  blisters,  will  be  found  of  the  greatest 
service,  hot  foot  baths,  etc.  If  the  inflammation  should  have  ad- 
vanced to  a  point  in  which  the  system  at  large  sympathizes,  as 
exhibited  by  the  presence  of  fever,  hope  is  still  to  be  entertained 
of  recovery  by  resolution.  In  these  cases  I  have  found  it  good 
practice  to  place  the  patient  over  a  basin  of  steaming  water,  and 
with  the  form  enveloped  up  to  the  very  mouth  in  blankets,  secure 
diaphoresis  by  a  plentiful  exhibition  of  the  spiritus  Mindereri — a 
tablespoonful  every  10  to  15  minutes  until  the  result  desired  is  pro- 
duced. This,  if  the  patient  is  robust,  may  be  succeeded  by  a  saline 
cathartic.  As  a  local  treatment,  it  will  be  found  very  agreeable  to 
order  a  lemonade,  made  by  crushing  ice  in  a  towel  or  napkin ;  the 
small  particles  of  the  ice  thus  acidulated  may  be  taken  little  by 
little  into  the  mouth,  and  allowed  gradually  to  dissolve.  Another 
application  consists  in  a  gargle  of  flaxseed  tea,  in  which  is  dis- 
solved the  chlorate  of  potash.  Tartar  emetic,  or  the  tinct.  of  digi- 
talis, or  of  verat.  viridum,  are  of  much  use  in  controlling  the  circu- 
lation. A  very  useful  combination,  where  the  circulation  runs  high 
and  the  system  is  irritable,  is  as  follows : 

R. — Liq.  potass,  citrat.  ^iij ; 
Spts.  seth.  nit.  ^i ; 
Tinct.  verat.  virid.  gtt.  xxv ; 
Ant.  et  potass,  tart.  gr.  i.     M. 
Sig.  From  3i  to  Jss,  according  to  circumstances. 

In  most  cases  of  tonsillitis  where  the  inflammation  is  extensive, 
the  uvula  will  be  found  to  participate  ;  swelling,  through  serous  effu- 
sions occurring,  not  unfrequently  to  such  an  extent  as  to  threaten  a 
very  immediate  suffocation.  I  know  of  nothing  more  satisfactory  in 
these  cases  than  the  draining  of  the  cellular  tissue  in  which  the  effu- 
sion exists  by  snipping  off  with  a  pair  of  scissors  the  tip  of  the 
organ.  In  the  swelling  of  the  glands  themselves,  where  danger  is 
apprehended  from  the  closure  of  the  passage,  or  overpressure  upon 

18 


274  ORAL  DISEASES  AND  SURGERY. 

the  epiglottis,  it  is  well  to  make  free  incisions,  or  these  failing,  to 
amputate  a  part  of  one  or  both  bodies.  Indeed,  circumstances  may 
arise  where  an  opening  into  the  larynx  or  trachea  may  aiford  the 
only  chance  to  a  patient  for  his  life. 

"Where,  in  defiance  of  all  treatment,  tonsillitis  determines  toward 
suppuration,  the  best  that  can  be  done  is  to  hasten  the  process  as 
rapidly  as  possible,  providing,  always,  that  the  attendant  swelling 
is  not  formidably  extensive.  In  these  latter  cases  nothing  better 
can  be  done  than  to  make  premature  incisions.  Where  the  swelling 
is  not  extensive  or  threatening,  gargles  of  flaxseed  tea  will  be  found 
both  soothing  and  encouraging  to  the  formation  of  pus,  and  may  be 
used  with  all  freedom. 

Hypertrophy,  or  chronic  enlargement  of  the  tonsils,  is  a  condition 
most  common  to  scrofulous  children,  and  pertains,  consequently,  to 
early  life,  being,  indeed,  very  rare  after  puberty,  and  never  perhaps 
seen  in  old  age  ;  of  the  various  patients  upon  whom  I  have  operated 
for  the  relief  of  this  affection,  I  do  not  recall  one  over  thirteen  years 
of  age.  An  enlarged  or  hj^iertrophied  tonsil  differs  very  much  in 
its  consistence  and  character,  being  in  one  patient  indurated  and 
smooth,  in  another  spongy  and  lobulated.  In  color  an  equal  variety 
is  presented,  varying  in  appearance  from  the  scarlet  of  an  arterial 
injection  to  the  dull  blue  of  a  passive  venous  stagnation.  One  of 
the  inconveniences  associated  with  enlarged  tonsils  is  the  effort  re- 
quired in  respiration,  particularly  during  sleep,  such  effoi't  in  many 
cases,  being  really  painful  to  witness.  Another,  is  the  interference 
with  hearing,  pressure  upon  the  Eustachian  tube  frequently  occlud- 
ing this  passage,  particularly  when  the  patient  takes  cold. 

Fig.  59. — Hypertrophied  Tonsil. 


Tonsillar  hypertrophy  being  a  systemic  expression  rather  than  a 
strictly  local  disease,  very  little  true  benefit  has  been  derived  from 
the  employment  of  the  great  variety  of  direct  remedies  which  from 
time  to  time  have  been  recommended.  A  patient  so  afflicted  is  to 
be  treated  from  the  constitutional  stand-point,  and  to  this  end  no- 


THE   TONSIL    GLANDS.  275 

thing  in  my  experience  has  been  more  conducive  to  change  than 
cold  salt-water  bathing;  indeed,  I  apprehend  that,  as  a  rule,  more 
attention  will  be  found  required  to  the  direction  of  diet,  clothing, 
exercise,  and  general  mode  of  life  than  to  the  administration  of  med- 
icine. Where,  however,  medication  seems  demanded,  it  is  to  be  di- 
rected to  the  correction  of  any  observable  constitutional  defect  or 
irregularity.  Iodine  and  its  preparations  are  not  always,  by  any 
means,  indicated ;  and  not  unfrequently,  in  their  exhibition,  by  a  fur- 
ther debasement  of  the  vital  powers,  much  more  harm  than  good  has 
resulted.  It  does  not  seem  possible  to  lay  down  rules  that  shall  or 
can  apply  to  the  constitutional  treatment  of  such  cases,  except  so  far 
as  to  suggest  attention  to  all  the  functions  and  the  general  tonic 
medication  always  demanded. 

Pressure  by  the  finger,  frequently  repeated,  punctures  with  the 
point  of  a  bistoury,  the  application  of  any  of  the  scorbifacients,  very 
dilute  gargles  of  the  tincture  of  capsicum, — any  or  all  these  means 
may  have  local  trial;  but  it  is  to  be  regretted  that  the  promise  is 
very  little. 

The  local  employment  of  the  iodide  of  zinc  has,  in  Europe,  re- 
ceived very  warm  commendations.  It  is  used  first  as  a  strong  solu- 
tion, from  ten  to  thirty  grains  to  the  ounce — afterward  pure,  or  as  it 
deliquesces  when  exposed  to  the  atmosphere. 

An  enlarged  tonsil,  truly  hypertrophied,  is  best  removed  by 
making  a  section  of  it.  To  this  end  the  instrument  known  as  the 
tonsillotome  is  always  to  be  recommended  ;  of  such  various  instru- 
ments, that  known  as  Fahnstock's  is  perhaps  the  best.  With  this, 
the  section  can  be  made  in  a  single  moment,  and  in  hands  at  all 
accustomed  to  operate,  without  the  slightest  risk. 

In  operations  upon  young  children,  with  the  tonsillotome,  it  will 
be  found  best  to  employ  ether,  as  otherwise  the  restlessness  may 
interfere  with  the  proper  introduction  of  the  instrument.     After  ex- 
cising one  tonsil  the  child  should  have  its  head  immediately  thrown 
forward,  that  the  blood  may  not  pass  into  the  throat.     As  soon  as 
hemorrhage  has  stopped,  the  ether  is  to  be  readmlnistered,  and  the 
section  repeated  upon  the  opposite  side. 
!      To  accomplish  this  operation  with  delicacy,  it  is  only  necessary 
;  to  place  one's  self  before  the  patient,  whose  head  is  suppoi-ted  against 
the  breast  of  an  assistant ;  the  tongue -holder  may  or  may  not  be  era- 
I  ployed,  as  seems  most  convenient.     In  cases  where  the  gland  may 
[  be  larger  than  permits  the  easy  application  of  the  instrument,  it 
j  will  be  found  very  useful  to  use  a  hook,  or  the  double  hook  forceps, 


276  ORAL  DISEASES  AND   SURGERY. 

pulling  the  body  into  the  fenestrum.  This  accomplished,  it  is  only 
necessary  to  slide  the  catch-pin.  When  the  gland  is  thus  fixed,  the 
blade  is  instantly  made  to  incise  it. 

Many  surgeons,  immediately  after  this  operation,  and  in  many  in- 
stances before  it,  administer,  in  anticipation  of  inflammatory  trouble, 
a  full  dose  of  sulphate  of  magnesia.  It  is  also  thought  well  by  many 
to  protect  the  incised  parts  against  the  irritating  influence  of  atmos- 
pheric changes  by  a  confinement  of  several  days  in  an  even  tempera- 
ture. I  think,  however,  that  if  the  weather  is  moderately  mild,  it 
may  be  found  sufficient  to  keep  the  parts  lubricated  by  a  coating  of 
gum  acacia,  secured,  by  simply  holding  the  pearls  in  the  mouth 
until  they  dissolve;  at  least,  such  practice  has  proven  very  satisfac- 
tory in  my  hands. 

Hemorrhage,  of  any  marked  character,  after  the  operation,  is  not 
common :  instances  occur,  however,  when  the  tonsillar  artery  must 
be  compressed,  twisted,  or  tied ;  but,  as  a  rule,  there  is  no  trouble 
from  this  source  that  a  simple  gargle  of  alum-water  will  not  be 
quite  sufficient  to  overcome. 

Ulceration. — Ulcers,  both  common  and  specific,  are  frequently 
met  with  upon  the  tonsils.  Nothing  peculiar  in  their  history  asso- 
ciates itself  with  the  situation;  they  are  to  be  treated  in  considera- 
tion of  their  varying  indications.  (See  Remarks  on  Ulcers.) 

Gangrene. — This  is  an  occasional,  though  very  rare  condition  ; 
when  appearing  independent  of  exanthematous  relations,  it  is  to  be 
looked  on  as  indicative  of  great  prostration  in  the  life  forces,  and 
must  be  expected  to  yield  alone  to  vigorous  constitutional  treatment. 
As  local  applications,  Watson's  chlorinated  water,  solutions  of  car- 
bolic acid,  or  starch-water  and  creasote  may  be  used. 

Cystic  Growths.  —  In  Professor  Gross's  System  of  Surgery 
reference  is  made  to  cystiform  enlargements  which  have  been  ob- 
.served  in  the  tonsils ;  with  such  conditions  I  have  never  happened 
to  meet.  The  treatment,  however,  would  necessarily  be  simple,  and 
would  be  entirely  analogous  to  that  of  ranula,  which  see. 

Acute  tonsillar  enlargement  sometimes  compels  the  performance 
of  laryngotomy  or  tracheotom3\  A  passing  study  of  these  opera- 
tions would  thus  seem  made  a  part  of  our  subject. 

When  convinced  that  a  patient  may  not  otherwise  be  relieved,  and 
sufi'ocation  is  eminent,  the  surgeon  may  thrust  a  bistoury  or  scalpel 
directly  through  the  crico-thyroid  membrane.  This  operation,  if  no 
middle  thyroid  artery  run  over  the  membrane,  is  one  of  most  simple 
character ;  and  if  the  parts  be  then  separated,  and  kept  so,  either  by 


THE   TONSIL    GLANDS. 


277 


the  introduction  of  a  tube,  or  by  hooks  of  wire,  which  may  pass 
around  the  neck,  the  patient  will  experience  the  greatest  relief 
When  the  artery  crosses  the  membrane,  and  has  thus  been  cut,  the 
blood  is  to  be  prevented  from  entering  the  lungs  by  leaning  the 
person  forward,  the  face  downward;  the  vessel  is  then  to  be  secured 
in  the  most  convenient  manner,  with  ligature,  if  possible. 


Fig,  60. — View  of  the  Air-Tubes. 

A.  B. 


A.  Larj-nx,  trachea,  and  bronchial  tubes,  viewed  in  front.  1,  hyoid  bone  ;  2,  thyro-hyoid 
membrane ;  3,  thyroid  cartilage ;  4,  crico-thyroid  membrane ;  5,  cricoid  cartilage  ;  6, 
trachea;  7,8,  two  cartilaginous  rings;  9,  membrane  which  separates  them;  10,  right 
bronchus  and  its  divisions ;  11,  left  bronchus. 

B.  Larynx,  trachea,  and  commencement  of  bronchial  tubes,  viewed  from  behind.  1, 
upper  opening  of  larynx;  2,  3,  lateral  grooves  of  larynx;  4,  fibrous  membrane  of  trachea. 
Interspersed  with  small  glands,  beneath  which  are  seen  5,  muscular  fibers  ;  beneath  this 
last  are  6,  7,  small  fibrous  bands ;  8,  mucous  membrane  seen  between  them. 


Tracheotomy  is  an  operation  which,  while  seemingly  complex,  is 
yet  most  easy  of  accomplishment,  at  least  I  have  found  myself  able 
to  perform  it  upon  the  living  subject  without  assistance.  Having 
the  patient  upon  his  back,  with  the  neck  extended,  an  incision  is 
to  be  made  directly  in  the  middle  line  of  the  neck ;  this  incision, 


278  ORAL  DISEASES  AND  SURGERY. 

under  the  circumstances  we  are  considering,  may  be  quite  short, 
and  is  to  be  commenced  immediately  below  the  cricoid  cartilage. 
Dividing  skin,  superficial  fascia,  and  the  delicate  layer  of  the  deep 
fascia,  we  come  upon  the  equilateral  muscles  running  from  the 
sternum  to  the  os  hyoides  and  thyroid  cartilage  ;  seeking  the  inter- 
space separating  these  muscles,  they  are  thrust  to  either  side, — this 
is  easily  done  by  using  the  handle  of  the  knife, — the  thyroid  plexus 
of  veins  is  now  brought  into  view,  and  is  to  be  carried  aside  or 
ligated,  as  seems  most  convenient;  these  manipulations  bring  into 
view  the  trachea  with  its  rings.  Take  now  the  tenaculum,  and, 
steadying  the  tube  by  pulling  it  upward,  incise  one,  two,  or  three 
rings. 

The  operation  thus  accomplished,  keep  the  incision  open  by  the 
use  of  the  wire,  or,  if  preferred,  introduce  the  canula  and  maintain 
it  in  place  by  the  strap,  as  seen  in  Subfig.  6,  Plate  VII. 

In  performing  the  operation,  it  is  also  necessary  to  bear  in  mind 
that  occasionally  the  inferior  thyroid  artery  is  found  lying  upon  the 
trachea,  directly  in  its  middle  line.  When  this  vessel  is  seen  it  be- 
comes necessary  to  throw  a  ligature  around  it.  My  own  observa- 
tions in  the  dissecting-room  would  lead  me  to  infer  its  presence  in 
this  position  in  about  one  out  of  six  cases. 

(Edema  of  the  glottis,  a  condition  sometimes  associated  with 
acute  tonsillitis,  is  a  very  dangerous  complication,  being  found 
generally  in  the  weak  and  anaemic.  This  complication,  when  really 
threatening,  may  be  aborted  by  blistering  the  neck  with  cantharidal 
collodion,  and  afterward  keeping  up  the  watery  discharge  by  paint- 
ing the  parts  with  glycerin.  If,  however,  such  a  treatment  is  not 
quickly  responded  to,  the  surgeon  finds  himself  compelled  to  scarify 
the  parts.  Subfig.  8  represents  this  swollen  condition  of  the  glottis. 
To  scarify  these  parts,  seat  the  patient  upon  a  chair,  and,  throwing 
the  head  well  backward,  introduce  the  finger  until  it  shall  touch  the 
epiglottis;  pressing  now  this  organ  toward  the  base  of  the  tongue 
so  that  the  finger  shall  be  back  of  it,  carry  a  curved  and  wrapped 
bistoury  along  the  finger  until  it  shall  reach  the  swelling ;  cuts  are 
now  to  be  made  from  below  forward.  If  the  epiglottis  is  the  part 
aifected,  and  this  is  most  commonly  the  case,  the  operation  is  ren- 
dered much  easier ;  steadying  the  organ  with  the  finger,  it  is  to  be 
incised  as  in  the  first  instance.  Subfig.  7  represents  oedema  of  the 
epiglottis. 


i 


jiiC; 


'y^ 


PLATE  VII. 

A  VIEW  OP  THE  OPERATIONS  PERFORMED  ON  THE  TRACHEA. 

Tig.  1. — A  front  view  of  the  Surgical  Anatomy  of  the  Trachea  1.  Os  hyoides. 
2.  Thyroid  cartilage.  3.  Thyro-hyoid  muscles.  4.  Crico-thyroid 
muscles.  5.  Thyroid  gland  and  veins  in  front  of  crico-thyroid 
ligament.  6.  Kings  of  the  trachea.  7.  Common  carotid  artery. 
8.  Superior  thyroid  arteries.  9.  Inferior  thyroid  artery.  10. 
Carotid  artery,  as  divided.  11.  Outline  of  the  top  of  the  chest. 
12.  Innominata  artery.  13.  Inferior  thyroid  vein.  14.  Trans- 
verse vein. — After  Bernard  and  Huette. 

Fig.  2. — Kelative  position  of  the  Larynx,  Trachea,  and  Blood-vessels.  1. 
Os  hyoides.  2.  Thyro-hyoid  ligament.  3.  Thyroid  cartilages. 
4.  Crico-thyroid  ligament.  5.  Cricoid  cartilage.  6.  Trachea.  7. 
Internal  jugular  vein.  8.  Transverse  vein.  9.  End  of  inferior 
thyroid  vein.     10.  Veins. — After  Bernard  and  Huette. 

Fig.  3. — Kelative  positions  of  the  great  vessels  concerned  in  operations  near 
the  top  of  the  sternum.  1,1.  Internal  jugular  vein.  2,  2.  Sub- 
clavian veins.  3.  Subclavian  artery.  4.  Transverse  vein.  5.  In- 
ferior thyroid  vein.  6.  External  jugular  vein.  7.  Arch  of  the 
aorta.     8,  8.  Primitive  carotids  — After  Bernard  and  Huette. 

Fig.  4. — A  view  of  the  operation  of  Tracheotomy,  as  performed  by  Mr.  Lis- 
ten. 1.  The  tenaculum  inserted  into  the  trachea.  2.  Position  of 
the  bistoury  in  incising  the  rings.  3.  Line  and  termination  of  the 
external  incision. — After  Liston. 

Fig.  5. — Extraction  of  a  foreign  body  by  Tracheotomy,  the  head  being  thrown 
back  and  lowered,  so  as  to  facilitate  the  gravitation  of  the  object. 
1,  1.  Blunt  hooks  holding  open  the  wound.  2.  Hand  of  the  sur- 
geon in  the  act  of  extracting  the  foreign  body,  by  drawing  it  up- 
ward from  the  bronchia. — After  Boiirgery  and  Jacob. 

Fig.  6. — A  front  view  of  the  position  and  mode  of  retaining  a  canula  in  the 
Trachea,  as  usually  practiced.  1.  The  incision.  2,  2.  A  tape  at- 
tached to  the  wings  of  the  canula  and  passing  around  the  neck. — 
After  Bernard  and  Huette. 

Fig.  7. — The  appearance  of  the  parts  concerned  in  (Edema  of  the  Glottis.  1. 
The  epiglottis  cartilage,  much  swollen  by  serous  infiltration  of  its 
submucous  cellular  tissue. — After  Gurdori  Buck,  Jr. 

Fig.  8. — The  operation  of  scarifying  the  Glottis  for  the  relief  of  (Edema.  1. 
The  forefinger  in  its  position  as  a  director.  2.  The  knife  in  the 
act  of  scarifying  the  part. — After  Gurdon  Buck,  Jr. 

(279) 


CHAPTER    XIX. 

THE   GUMS   AND   THEIR   DISEASES. 

The  gums  are  simply  a  greater  or  lesser  amount  of  fibro -carti- 
laginous tissue  (the  fibrous  far  predominating)  placed  as  protecting 
cushions  about  the  alveolar  processes.  The  neck  of  each  tooth  is 
closely  enveloped  by  the  dental  pits  of  this  cushion ;  the  mucous 
membrane,  which  covers  the  common  surface,  being  reflected  around 
the  pits,  and  rendered  continuous  with  the  periosteum  of  the  alveoli. 
The  gums,  in  a  healthy  state,  are  rather  remarkable  for  their  in- 
sensibility, bearing,  with  very  little  or  no  response,  the  pressure  and 
irritation  to  which,  in  the  process  of  mastication,  they  are  so  con- 
tinuously subjected.  The  mucous  membrane,  of  which  this  tissue 
is  really  largely  made  up,  is  very  heavy  and  thick  compared  with 
its  continuity  in  other  parts  of  the  alimentary  canal,  and  is  under- 
laid by  a  network  of  vessels,  which  leads  it  to  be  esteemed  of  con- 
siderable vascularity  as  reference  is  had  to  operations  involving  it. 

Inflammation  is  the  disease  of  the  gums,  but  such  perverted  vas- 
cular action,  here,  as  everywhere  else,  has  quite  a  variety  of  signifi- 
cations.    These  significations  are — 
1st.  Accumulations  of  tartar. 
2d.  Periodontitis. 
3d.  The  mercurial  impression. 
4th.  Scurvy. 
5th.  Syphilis. 
6th.  Dead  or  loose  teeth. 
7th.  A  crowded  dental  arch. 
8th.  Use  of  improper  dentifrices  and  brushes. 
9th.  Improperly  inserted  artificial  teeth. 
10th.  Malignant  impressions. 
11th.  Anomalous  conditions. 

A  comprehension  of  the  diseases  of  the  gums  is  found  in  the  ap- 
preciation of  these  various  conditions  or  influences. 

1st.  Accumulations  of  Tartar.— SaMvavj  calculus,  a  deposit  from 
(280) 


THE   GUMS  AND    THEIR   DISEASES.  281 

the  saliva,  combined  with  the  various  oral  debris,  when  attached  about 
the  necks  of  the  teeth,  necessarily  becomes  a  source  of  offense,  pro- 
voking inflammatory  action,  the  grade  of  which  is  marked  by  the 
general  condition  of  the  individual.  The  most  common  type  of  in- 
flammation thus  induced  is  the  chronic  degenerative.  The  tartar, 
pressing  upon  the  gums  and  insinuating  itself  about  and  around  the 
necks  of  the  teeth,  soon  interferes  to  such  extent  with  the  proper  cir- 
culation in  the  part  as  to  yield  the  puffy,  turgid  condition,  so  familiar 
in  most  of  the  cases.  The  mucous  follicles  lining  the  muco-dental 
pits  have,  of  course,  their  secretive  ability  soon  destroyed,  and  thus 
nothing  prevents  the  insinuation  of  particles  into  these  pits,  and  the 
consequent  increase  in  the  power  of  the  offense.  This  irritation,  un- 
combated,  gradually  progresses  until  the  teeth  become  loosened  and 
fall  out,  when,  carrying  with  them  the  tartar,  the  parts  recover. 

All  deposits,  however,  existing  under  the  common  name  of  tartar 
or  salivary  calculus,  do  not  have  such  a  destructive  history.  Thus, 
it  is  very  common  to  observe  a  greenish  deposit,  particularly  upon 
the  teeth  of  the  robust  and  uncleanly,  which,  so  far  as  I  have  ob- 
served, seldom  results  in  any  particular  harm.  Another  kind,  the 
black,  rarely  exists  but  in  very  limited  amount,  and  as  rarely  or  never 
does  any  greater  ill  than  slightly  irritating  the  festoon  ;  its  situation 
is  most  commonly  the  lingual  face  of  the  inferior  teeth.  It  does  hap- 
pen, however,  that  this  description  of  tartar,  or  something  very  anal- 
ogous to  it,  is  sometimes  provoked,  as  it  were,  in  depraved  constitu- 
tions, to  extensive  deposit ;  it  is  a  kind  of  mixture  or  agglutination 
of  tartar  and  sordes.  The  gums,  from  a  constitutional  influence,  very 
much  depraved,  are  irritated  not  unfrequently  by  this  jagged  de- 
posit into  a  state  very  little  short  of  gangrene ;  the  breath  is  made 
offensive,  and  the  oral  fluids,  by  the  admixture,  rendered  entirely 
unfit  to  be  received  by  the  stomach. 

Yellow  tartar,  the  deposit  of  the  bilious  and  allied  temperaments, 
is  the  kind  most  generally  met  with,  and,  as  a  rule,  is  most  destruc- 
tive to  the  integrity  of  the  teeth  and  gums.  It  is  not  at  all  uncom- 
mon to  find  this  deposit  of  such  extent  as  to  inclose  in  a  common 
mass  half  a  dozen  or  more  teeth,  while  its  power  of  insinuation  and 
destruction  is  so  great  that,  before  attention  may  have  been  directed 
to  the  process,  the  alveoli  will  be  found  destroyed  and  the  teeth 
ready  to  drop  from  the  mouth.  I  have,  in  my  own  practice,  fre- 
quently been  consulted  in  these  cases,  where  nothing  was  of  any 
avail  but  the  removal  of  the  implicated  teeth.  This  description  of  cal- 
culus is  evidently  a  direct  deposit  from  the  saliva,  its  situation  cor- 


282  ORAL   DISEASES  AND   SURGERY. 

responding  with  the  location  of  the  salivary  orifices.  I  think  it  will 
be  found  always  associated  with  a  sluggish  condition  of  the  secretive 
action  of  the  glands,  as  I  am  sure  its  most  reliable  prophylaxis  is 
found  in  their  stimulation.  This  tartar  has  a  rough,  dry  surface,  and 
is  "-enerally  most  easy  of  removal,  flaking  away  in  masses  at  the 
slightest  touch  of  the  instrument.  The  effect  of  its  presence  upon 
the  gum  is  to  force  it  away  from  the  teeth,  or  rather,  it  might  be 
more  correct  to  say,  to  lift  the  teeth  from  the  gums  and  their  alveoli, 
destroying  entirely  any  relation  of  attachment  between  the  parts. 
The  gums  themselves,  under  its  irritating  influence,  become  puffy 
and  soft,  and  occasionally  so  tender  as  to  render,  in  many  cases,  un- 
bearable the  ordinary  pressure  exerted  in  mastication,  so  that  the 
patient  is  compelled  to  subsist  exclusively  on  soft  food,  or  employ 
other  than  the  natural  process  of  comminution.  (See  Chapter  on 
Salivary  Calculus. ) 

2d.  Periodontitis. — Ulitis  from  periodontitis  is  not  at  all  difficult 
to  distinguish,  and  corresponds  in  character  with  the  primary  lesions 
in  being  acute  or  chronic.  If  a  tooth  is  acutely  inflamed  in  its  perio- 
donteum,  it  is  sore  to  the  touch,  and  elongated.  If  it  is  chronically 
inflamed,  it  is  loose  or  discolored.  Inflammation  in  the  gum  is 
simply  an  inflammation  of  continuit}^.  If  the  patient  is  in  good 
health,  the  action  will  be  circumscribed ;  if  the  reverse,  it  may  of 
course  influence.  To  treat  such  an  inflammation,  the  health  of  the 
tooth  or  teeth  is  to  be  restored.  An  inflamed  periodonteum  is  com- 
monly associated  with  a  dead  pulp ;  this  is  the  first  source  of  offense  for 
which  we  naturally  look.  If  such  a  condition  is  found,  and  no  cavity 
of  communication  exists  with  the  pulp  canal,  it  will,  in  nine  cases 
out  of  ten,  only  be  necessary  to  make  such  communication,  and  the 
trouble  quickly  enough  disappears.  Tartar  is  the  frequent  source 
of  chronic  periodontitis.  Fish  bones,  or  other  foreign  bodies,  forced 
into  the  membrane  in  mastication,  excite  inflammation. 

Acute  periodonto-ulitis  uncontrolled  ends  in  parulis,  and  from  such 
acute  termination  is  very  apt  to  pass  to  chronicity.  Chronic  ulitis 
presents  the  condition  of  continued  turgescence,  soreness,  loose  teeth, 
or  fangs;  suppuration  frequently  occurs  at  the  seat  of  the  original 
abscess,  and  sometimes,  from  the  affected  alveolar  pits,  its  cure,  like 
that  of  the  acute  condition,  resides  in  a  treatment  directed  to  the 
teeth.  (See  Periodontitis  and  Alveolar  Abscess.) 

3d  Tlie  Mercurial  Imjyression. — Mercury  first  yields  decided  evi- 
dence of  its  action  by  producing  in  the  mouth  a  metallic  taste,  com- 
plained of  as  coppery.     A  little  time,  and  this  taste  is  accompanied 


THE   GUMS  AND    THEIR  DISEASES.  283 

with  some  increase  in  the  quantity  of  the  saliva;  still  later  the 
festoons  of  the  gums  will  be  found  congesting,  commencing  generally 
about  the  necks  of  the  lower  central  teeth.  Succeeding  this  conges- 
tion we  have  the  dull  whiteness,  indicating  the  change  in  the  epi- 
thelial tissue  (a  form  of  aphthae).  There  now  follows  the  elongation 
of  the  teeth,  increased  salivary  flow,  stiffness  of  the  gums,  enlarge- 
ment of  the  tongue,  foul  breath,  etc. 

The  efi'ects  which  mercury  shall  produce  on  the  mouth,  or  system 
at  large,  depends  on  the  quantity  administered  and  the  susceptibility 
of  the  individual.  I  have  myself  exhibited  the  medicine  in  quantities 
of  from  fifteen  to  twenty  grains  in  the  course  of  three  days  without 
being  able  to  perceive  the  local  action;  while,  on  the  contrary,  I  have 
known  five  grains  to  so  swell  the  tongue  that  it  required  much  effort 
to  prevent  the  patient  being  smothered.  Children  from  five  to  ten 
years  of  age  have  seemed  to  me  markedly  susceptible.  I  removed, 
a  short  time  back,  the  whole  of  the  left  half  of  the  body  of  the  lower 
jaw,  dead  from  but  some  three  grains  of  calomel,  as  averred  by  the 
practitioner  who  administered  the  medicine  The  patient  was  seven 
years  of  age.  Mercurial  ulitis,  when  confined  alone  to  these  parts, 
signifies  but  slight  effect  on  the  part  of  the  action  of  the  agent ;  and 
the  immediate  cessation  in  its  employment  will  generally  result  in 
the  disappearance  of  these  effects.  If  this  should  not,  however,  prove 
the  case,  I  think  nothing  better  can  be  done  than  to  scarify,  and 
paint  the  gums  with  tinct.  of  iodine,  graduated  to  each  particular 
case,  say,  as  a  rule,  half  and  half  of  the  officinal  tincture  and  water. 
Chlorate  of  potash  as  a  wash,  and  used  internally,  may  also  be  em- 
ployed. To  an  adult,  ten  grains  of  the  salt,  dissolved  in  a  table- 
spoonful  of  water,  may  be  given  four  or  five  times  in  a  day.  As  a 
local  application,  one  drachm  to  the  ounce  of  water  is  a  very  good 
strength.  The  bowels  are  to  be  kept  in  a  lax  condition  by  the  ad- 
ministration of  Seidlitz  powders  or  other  saline  cathartics.  Where 
mercurial  ulitis  passes  to  that  stage  which  results  in  the  breaking 
down  of  the  tissue,  and  this  is  sometimes  the  case  where  even  ad- 
jacent parts  are  not  markedly  affected,  the  treatment  required  is 
much  more  imperative,  and  pertains,  as  a  rule,  quite  as  much  to  the 
constitution  at  large  as  to  the  mouth  itself.  Locally,  the  fetor  will 
urgently  demand  attention,  and  one  of  the  best  means  to  correct 
this  will  be  found  in  the  use  of  a  solution  of  the  permanganate  of 
potash,  such  solution  varying  in  strength  from  two  to  ten  grains  to 
the  ounce  of  water.  Constitutionally,  vigorous  tonic  medicaments  are 
required, — not  the  least  important  of  which  are  the  iron  and  bark 


284  ORAL  DISEASES  AND  SURGERY.  i 

preparations.  If  hemorrhage  intervenes,  it  may  be  necessary  to  era-  j 
ploy  opium  and  lead  internally ;  or,  as  suggested  in  another  part  of  j 
this  work,  tinct.  Erigeron  Canadense,  in  doses  of  one  or  two  drops, 
repeated  occasionally  until  such  bleeding  is  controlled.  Locally, 
cobweb  saturated  in  alum-water  may  be  used.  Laid  carefully  upon 
the  bleeding  part,  and  retained  in  position,  it  will  seldom  be  found 
to  fail.  Monsel's  solutions  should  not  be  used.  The  tendency  in 
extreme  cases  toward  sloughing  is  a  matter  constantly  to  be  borne 
in  mind.  When  the  tumefaction  is  very  great  and  indolent-looking, 
the  parts  are  still  to  be  incised  and  the  iodine  applied ;  but  both 
remedies  are  to  be  used  with  judgment  and  caution.  I  have  known 
gums  in  the  condition  alluded  to,  and  which  might  perhaps  have 
been  recovered,  sloughed  in  mass  by  applications  of  strong  tincture  of 
iodine.  Always  let  the  incisions  at  first  be  few,  and  the  tincture  at 
least  two-thirds  diluted.  The  dilute  aromatic  sulphuric  acid  is  also 
a  happy  local  remedy  in  these  conditions.  It  may  be  mixed  with 
water  until  the  acid  taste  is  comfortably  bearable — about  5i  to  5viij 
of  water.  A  combination  which  I  also  occasionally  use  with  much 
benefit  is  composed  as  follows : 

B. — Potassse  chloras,  §ss ; 
Sodae  boras, 
Alumen  pulv.  aa  Jij ; 
Potass,  permang.  grs.  xxv ; 
Aqua  cologn.  ^ss ; 
Tinct.  cinchonas,  ^ij ; 
Tinct.  myrrhae,  §i; 
Infus.  quercus  (fort.)  ^iv.    M. 
Sig.  Gargle  the  mouth  pro  re  nata. 

If,  in  defiance  of  all  that  is  done,  the  parts  should  slough,  one  of 
three  things  occur:  the  disease  will  seem  to  have  exhausted  itself, 
and  the  parts,  after  a  little  rest,  give  evidence  of  recovery ;  or  the 
bone  follows  the  ulcerative  action,  and  sloughs  likewise ;  or  the 
patient  dies  from  irritation  and  exhaustion.  (For  treatment  of  Caries 
and  Necrosis,  see  other  pages.) 

4th.  ScAirvy. — Scurvy  proper,  such  as  decimated  the  legions  of 
Louis  the  Ninth,  and  in  even  later  days  was  so  frequently  the 
scourge  of  protracted  sea  voyages,  is  a  condition  which  modern 
science  and  judgment  have  so  combated  that  it  may  be  trusted  that 
few  of  us  will  ever  have  occasion  to  meet  with  or  treat  it.  Modified 
forms  of  the  disease  are  still,  however,  prevalent  enough,  and  exist, 


THE   GUMS  AND    THEIR   DISEASES.  285 

with  great  variety  of  features,  from  simple  indolent  ulitis  to  general 
I  purpura. 

j      Puffiness  of  the  gums,  scorbutic   in  nature,  is  fairly  judged,  I 
'  think,  from  its  dull,  purple  aspect,  independent  of  its  varying  consti- 
I  tutioual  conditions  ;  this  venous  congestion  compares  pathologically 
i  with  the  effusions  of  purpura  proper.     It  would  not,  however,  be  at 
:  all  truthful,  or  in  accordance  with  the  facts,  to  describe  any  particu- 
lar train  of  constitutional  conditions  as  constantly  associated  with 
the  scorbutic  sore  mouth,  as  met  with  in  ordinary  practice,  and  for  the 
reason  that  nothing  else  of  the  disease  may  appear  but  the  local 
manifestation.     That  it  is  a  constitutional  affection,  however,  and 
not  a  local  disease,  is  proven  from  the  fact  of  absence  of  any  source 
of  local  irritation,  and  from  the  further  fact  of  its  constant  presence 
in  the  mouth,  let  the  disease  possess  whatever  other  manifestations 
it  may. 

"  Scurvy,"  says  Dr.  Wood,  "is  generally  very  gradual  in  its  ap- 
proach, so  that  it  is  scarcely  possible  to  say,  in  any  particular  case, 
what  was  its  precise  time  of  attack.  Attention  is  commonly  first 
attracted  by  an  unhealthy  paleness  of  complexion,  a  feeling,  on  the 
part  of  the  patient,  of  languor  and  despondency,  with  an  indisposi- 
tion to  bodily  action,  and  unusual  fatigue  after  exercise ;  a  sensation 
of  weariness  and  aching  in  the  limbs  as  from  overexertion,  though 
the  patient  may  have  been  at  rest ;  and  some  swelling,  redness,  and 
tenderness  of  the  gums,  with  a  tendency  to  bleed  from  slight  causes. 
With  the  advance  of  the  disease  the  face  becomes  paler,  and  assumes 
a  somewhat  sallow  or  dusky  hue,  and  often  a  degree  of  puffiness ; 
the  lips  and  tongue  become  pallid,  and  contrast  strikingly  with  the 
gums,  which  are  purple  or  livid,  especially  at  their  edges,  rise  up 
between  and  around  the  teeth,  are  soft  and  spongy,  and  bleed  from 
the  slightest  touch ;  the  breath  is  ofiensive ;  purplish  spots  or 
blotches  appear  upon  various  parts  of  the  surface,  beginning  usually 
upon  the  lower  extremities  and  afterward  extending  to  the  trunk, 
arms,  and  neck,  though  seldom  affecting  the  face ;  hemorrhage  fre- 
quently occurs,  most  commonly  from  the  nose,  gums,  and  mouth,  but 
sometimes  also  from  the  stomach,  bowels,  and  urinary  passages;  the 
feet  become  edematous,  and  the  legs  swollen  and  painful ;  the  gen- 
eral debility  increases  ;  and  muscular  exertion  is  apt  to  be  attended 
with  palpitation  of  the  heart,  panting,  vertigo,  dizziness,  and  a  feel- 
ing of  faintness.  The  petechial  spots  are  obviously  owing  to  the 
extravasation  of  blood  within  the  cutaneous  tissue.  Occasionally 
portions  of  the  surface  look  as  if  bruised  without  having  suffered 


286 


ORAL  DISEASES  AND  SURGERY. 


anv  violence;  and  blows,  which,  under  ordinary  circumstances 
would  produce  no  effect,  now  give  rise  to  extensive  ecchymosis. 
Should  the  disease  continue,  all  the  symptoms  become  aggravated, 
the  complexion  assumes  often,  with  its  paleness,  a  livid  or  leaden 
hue  •  the  gums  swell  greatly,  and  put  forth  a  blackish  fungous 
gi-owth,  so  as  sometimes  to  conceal  the  teeth,  blood  continually  oozes 
from  them  ;  sloughing  occasionally  takes  place,  laying  bare  the  necks 
of  the  teeth,  and  extending,  in  very  bad  cases,  even  to  the  cheek. 
The  teeth  become  loose,  and  sometimes  fall  out;  the  patient  is  un- 
able to  chew  solid  food  in  consequence  of  the  state  of  his  gums. 
The  breath  becomes  intolerably  offensive  ;  hard  and  painful  tumefac- 
tions occur  in  the  calves  of  the  leg,  among  the  muscles  of  the  thigh, 
upon  the  tibiae  and  lower  jaw,  and  in  the  hand,  with  stiffness  and 
contraction  of  the  joints,  especially  the  knee,  and  severe  pain  in  the 
extremities  upon  every  attempt  at  movement;  and  the  debility,  be- 
fore so  prominent  a  feature  in  the  case,  now  becomes  excessive,  so 
that  the  least  exertion  is  dangerous,  and  the  patient  sometimes  dies 
suddenly  upon  rising  from  bed,  or  upon  being  conveyed,  without 
great  caution,  from  one  place  to  another.  Wounds,  even  slight 
scratches,  degenerate  into  unhealthy  ulcers ;  old  cicatrices  break  out 
afresh,  and  existing  ulcers  assume  a  new  and  much  worse  aspect. 
The  bones  are  said  to  be  softened,  united  fractures  are  again  opened, 
and  in  the  young,  the  epiphyses  separate  sometimes  from  the  shaft. 

"  Throughout  the  complaint  the  tongue  is  usually  clean  and  moist, 
and  the  appetite  and  digestion  remain  unimpaired  almost  to  the 
last,  unless  the  disease,  as  sometimes  happens,  should  be  complicated 
with  fever.  Indeed,  there  is  often  a  craving  for  food,  especially  for 
fresh  vegetables  and  fruits;  occasionally,  however,  there  is  vomiting, 
with  epigastric  distress  and  other  evidences  of  stomachic  disorder. 
The  bowels  are  mostly  costive,  and  in  some  cases  obstinately  so, 
but  diarrhoea  not  unfrequently  intervenes,  with  black  or  bloody  and 
offensive  evacuations.  The  pulse  is  generally  small,  feeble,  and 
slow,  but  cases  occur  in  which  it  becomes  very  frequent,  and  the 
surface  of  the  skin  febrile,  probably  from  the  sympathy  of  the  sys- 
tem with  various  local  irritative  congestions.  Great  emaciation  usu- 
ally attends  the  disease  when  severe  or  lasting,  but  not  invariably. 
Little  cerebral  disturbance  is  ordinarily  observable,  and  the  patient 
often  retains  full  possession  of  his  senses  and  intellect  to  the  last," 

This  description,  condensed  from  Dr.  Wood's  valuable  paper  on 
the  subject,  describes  the  disease  in  perhaps  its  severest  forms; 
I  have  never  seen  such  cases  of  scurvy,  although  at  different  times 


THE   GUMS  AND    THEIR   DISEASES.  28T 

meeting  considerable  of  it  as  manifested  in  the  persons  of  sailors 
and  others  brought  to  hospitals  for  treatment.  Dr.  Foltz,  TJ.  S.  N. 
in  a  report  made  by  him  on  the  scurvy  which  appeared  in  the 
blockading  fleet  of  the  Gulf  of  Mexico,  states  that  "lassitude  and 
indisposition  to  muscular  energy  were  not  among  the  symptoms 
which  ushered  in  the  disease,  and  that  there  was  great  activity, 
and  not  unfrequently  cheerfulness,  good  appetite,  and  sound  sleep 
at  night,  after  the  teeth  were  loosened,  the  gums  ulcerated,  the 
limbs  edematous  and  discolored ;  and  when  at  last  the  patient  gave 
way,  it  was  not  an  indisposition  to  corporal  exertion,  but  an  actual 
disability." 

Authors,  however  much  they  may  disagree  in  their  descriptions 
of  such  various  cases  as  have  come  under  their  observation,  are 
all  agreed  that  scurvy  results  from  the  absence  of  fresh  fruits  and 
vegetables,  or  their  juices,  necessary  to  furnish  some  principle  re- 
quired in  the  blood,  and  which  is  not,  in  such  absence,  otherwise 
obtained.  In  the  treatise  published  by  Dr.  Hamilton  on  Military 
Surgery,  the  author  says :  In  regard  to  the  pathology  of  scurvy, 
the  belief  prevails  that  it  is  due  essentially  to  the  absence  of  certain 
staminal  principles  from  the  blood,  and  especially  potash.  It  ap- 
pears to  be  a  pretty  well  ascertained  fact  that  all,  or  nearly  all,  of 
those  remedies  which  have  been  employed  successfully  in  the  pre- 
vention or  cure  of  scurvy,  contain  potash.  Potatoes,  cabbage,  cel- 
ery, lettuce,  lime,  lemon,  and  orange  juice  contain  it  in  large  quan- 
tity, unless  their  salts  have  been  expressed  by  the  application  of  heat, 
as  in  boiling,  or  other  modes  of  cooking.  Lime,  lemon,  and  orange 
juice  contains  nearly  one  grain  of  potash  to  every  ounce  of  the  juice. 

One  ounce  of  potatoes  yields  one  grain  and  a  half,  while  one  ounce 
of  rice  yields  only  -005  of  a  grain.  The  substitution  of  rice  in  an 
English  workhouse  for  an  equal  amount  by  weight  of  potatoes  was 
followed  in  a  short  time  by  scurvy. 

In  the  ordinary  scurvy  of  the  gums,  which  every  practitioner  is 
aware  presents  itself  more  frequently  in  the  very  early  spring,  when 
the  old  vegetables  have  been  pretty  well  exhausted  and  the  fresh 
ones  have  not  begun  to  grow,  it  is  the  common  experience  to  dis- 
cover that  the  patients  have  existed  almost  exclusively  on  salt  meats ; 
hence  it  is  much  the  most  frequently  met  with  in  the  poorer  class 
of  farm-laborers.  The  gums,  in  these  cases,  are  of  a  purple  color, 
turgid,  with  the  dental  pits  discharging  pus,  the  teeth  loosened,  the 
breath  offensive,  but  the  face  not  by  any  means  pale,  nor  the  habits 
languid ;  indeed  there  is  little  or  nothing  to  signify  that  the  local 


288  ORAL  DISEASES  AND   SURGERY. 

manifestation  is  a  systemic  ofifspring.  When  the  condition  is  ex- 
treme, it  is  not  uncommon  to  have  fungoid  growths  (epulo-fungoid 
tumors),  alluded  to  by  Dr.  Wood,  springing  from  the  edges  and 
depths  of  the  dental  pits. 

Treatment. It  will  be  found  good  practice  to  treat  these  con- 
ditions locally,  as  directed  in  mercurial  ulitis.  Constitutionally, 
however,  different  indications  are  to  be  met ;  a  something  pos- 
sessed by  a  vegetable  and  acid  diet  is  required  by  the  blood ;  with- 
out stopping  to  discuss  the  question  whether  this  may  or  may 
not  be  potash,  we  act  on  the  empirical  conviction,  and  at  once 
direct  such  diet.  Then  the  depressed  or  perverted  life  force  is  to 
be  elevated  or  relieved,  and  to  this  end  nothing  can  equal  the  sheet- 
bath,  taken  with  water  moderately  warm  and  moderately  salt:  satu- 
rating the  sheet,  it  is  quickly  thrown  around  the  body,  and  the 
patient  or  an  assistant  rubs  the  sheet  over  the  flesh  until  the  whole 
person  is  in  a  ruddy  glow ;  this  is  repeated  each  morning  imme- 
diately on  rising. 

As  medicine,  the  vegetable  acids  may  be  freely  used.  Lemonade 
is  perhaps  quite  as  good  as  anything  that  can  be  given.  A  combi- 
nation which  has  some  celebrity,  is  known  as  Turner's  antidote ;  it 
consists  of  3ij  of  potassse  nitratis,  mixed  in  §viij  acidi  acetici,  ad- 
ministered in  tablespoonful  doses  ter  die. 

5th,  Syphilis. — Syphilitic  ulitis,  I  judge,  from  my  own  experi- 
ence and  observation,  not  to  be  an  inflammation  of  the  gum  tissue 
proper,  but  simply  of  its  mucous  envelope,  or,  on  the  other  hand,  it 
is  an  inflammation  commencing  in  the  periosteum,  and  secondarily 
affecting  the  gum  tissue.  I  do  not  think  I  have  ever  seen  a  case  of 
pure  uncomplicated  syphilitic  ulitis,  while  few  conditions  are  more 
common  than  mercurio-syphilitic  ulitis  and  osteo-ulitis  of  syphi- 
litic origin.  The  appreciations  of  such  conditions  are,  of  course, 
not  at  all  difficult ;  the  history  of  the  case  alone  is  sufficient  to  give 
the  diagnosis,  while  to  the  experienced  eye  a  moment's  glance  is 
enough  to  reveal  such  history.  If  the  inflammation  is  confined  to 
the  mucous  membrane,  the  full  extent  of  its  surface  will  be  more  or 
less  affected,  its  color  will  be  a  dull  red,  it  will  be  more  or  less 
tender  to  the  touch,  and  most  likely  ulcerated.  If,  on  the  contrary, 
the  bone  or  its  periosteum  is  the  primary  seat  of  trouble,  the  gum 
may  simply  be  thrown  up  by  the  effusion  beneath  it ;  or  if  it  happens 
that  the  gum  itself  has  become  inflamed,  the  action  seems  inclining 
to  localize  itself  as  much  as  possible  This,  however,  depends  on  the 
state  of  the  parts  beneath,  and  the  treatment  that  is  being  pursued. 


THE   GUMS  AND    THEIR   DISEASES.  289 

If  the  condition  is  one  of  pure  uncomplicated  venereal  ostitis,  the  ex- 
citement in  the  gum  will  be  found  localized  to  the  immediately  over- 
lying parts ;  but  if  a  mercurial  treatment  has  been  pursued,  we  then 
may  have  any  extent  of  complication.  The  treatment  to  be  pursued 
in  these  cases  is  to  be  founded  on  existing  conditions. 

6th.  Dead  or  Loose  Teeth. — Dead  teeth  affect,  secondarily,  the 
gum  structure  by  continuity  with  the  inflamed  periodonteum.  A 
dead  tooth,  pcriosteally  inflamed,  is  always  sore  to  the  touch,  is  more 
or  less  elongated,  and  is  discolored.  An  ulitis  connected  with  such 
diseased  tooth  or  teeth  is  plainly  discoverable  by  the  absence  of 
other  sources  of  irritation ;  relief  follows,  of  course,  the  cure  of  the 
primary  lesion. 

7th.  Overcroicded  Condition  of  the  Dental  Arch. — (See  Chapter 
on  Anomalie»of  Dentition.) 

8th.  Use  of  Improper  Dentifrices  and  Brushes. — Many  gums  are 
subjected  to  continuous  irritation  and  inflammation  from  the  use  of 
agents  in  the  way  of  dentifrices,  brushes,  or  other  dental  applica- 
tions, which,  either  chemically,  vitally,  or  mechanically,  predispose 
and  excite  to  deterioration.  Perhaps  in  the  whole  range  of  practice 
there  is,  in  no  single  instance,  less  attention  given  to  the  require- 
ments of  the  various  cases  than  is  manifested  in  the  prescribing  of 
tooth-cleansing  powders  and  washes.  Charcoal,  a  favorite  agent  with 
many,  while  most  excellent  in  its  place,  is  one  of  the  most  abused  of 
these  remedies.  How  very  common  is  it  to  find,  after  a  few  weeks 
or  months  of  the  use  of  this  material,  the  gums  becoming  pitted 
with  black  spots  about  the  necks  of  the  teeth  and  loosening  from 
them.  This  is  a  result  of  the  insolubility  of  the  agent  in  the  fluids 
of  the  mouth ;  gradually,  but  surely,  it  finds  its  way  within  the 
mucous  pits,  and  not  being  either  washed  out  or  dissolved  by  the 
secretion,  it  quickly  enough  destroys  the  integrity  of  the  relation  ; 
hence  follows  chronic  periodontitis  and  the  eventual  loss  of  the 
teeth, — the  mass  of  gum  tissue  sympathizing  during  the  whole 
period, — producing  chronic  ulitis. 

Pulverized  coral  and  pumice  are  other  agents  mechanically  de- 
structive, although  in  their  places  very  good,  and,  as  will  be  re- 
marked, recommended.  Castile  or  other  soaps,  too  freely  used, 
degenerate  by  the  action  of  their  alkalinity.  Thus  a  constant  use 
of  such  agents  is  quite  certain  to  be  attended  by  puffiness  and 
chronic  turgidity  of  the  gums,  by  degenerated  mucous  discharges, 
and  by  an  offensive  breath.  Acids,  on  the  other  hand,  employed  of 
too  full  a  strength,  inflame  and  irritate  the  gums,  put  the  teeth  on 

19 


290  ORAL  DISEASES  AND  SURGERY. 

edge,  by  dissolving  their  mucous  envelopes  and  more  or  less  of  their 
limo  salts.  An  ulitis  from  the  irritation  of  acid  agents  differs,  hovr- 
evor,  from  that  produced  by  the  alkaline,  in  being  of  a  free,  gener- 
ous, acute,  or,  at  worst,  subacute  nature,  easy  of  control,  and  much 
more  injurious  to  the  teeth  than  to  the  gums  themselves.  Irritation 
of  the  gums  commonly  associates  with  injury  done  to  the  teeth. 
We  may  refer  to  the  following  most  interesting  experiments  per- 
formed several  years  back  by  Dr.  A.  Westcott: 

"  1st.  Both  vegetable  and  mineral  acids  act  readily  upon  the  bone 
and  enamel  of  the  teeth. 

"  2d.  Alkalies  do  not  act  upon  the  enamel  of  the  teeth ;  the  caustic 
potash  Avill  readily  destroy  the  bone  by  uniting  with  its  animal 
matter. 

"  3d.  Salts  whose  acids  have  a  stronger  affinity  for  the  lime  of 
the  teeth  than  for  the  basis  with  which  they  are  combined  are  de- 
composed, the  acids  acting  upon  the  teeth. 

"  4th.  Vegetable  substances  have  no  effect  on  the  teeth  till  after 
fermentation  takes  place ;  but  all  such  as  are  capable  of  acetic  fer- 
mentation act  readily  after  this  acid  is  formed. 

"  5th.  Animal  substances,  even  while  in  a  state  of  confined  putre- 
faction, act  very  tardily,  if  at  all,  upon  either  the  bone  or  enamel. 
On  examining  the  teeth  subjected  to  such  influences,  the  twentieth 
day  of  the  experiment,  no  visible  phenomena  were  presented  except 
a  slight  deposit  upon  the  surface  of  a  greenish,  slimy  matter,  some- 
what resembling  the  green  tartar  often  found  upon  teeth  in  the 
mouth." 

Dr.  Westcott  also  adds  the  following  experiments  with  agents  in 
very  common  use,  some  of  which  are  very  frequently  most  loosely 
and  injudiciously  prescribed  in  tooth-washes  and  powders  : 

"Acetic  and  citric  acids  so  corroded  the  enamel  in  forty-eight 
hours  that  much  of  it  was  easily  removed  with  the  finger-nail, 

"Acetic  acid,  or  common  vinegar,  is  not  only  in  common  use  as  a 
condiment,  but  is  formed  in  the  mouth  whenever  substances  liable 
to  fermentation  are  suffered  to  remain  about  the  teeth  after  any  con- 
siderable length  of  time. 

"  Citric  acid,  or  lemon  juice,  though  less  frequently  brought  in 
contact  with  the  teeth,  acts  upon  them  still  more  readily. 

"  Malic  acid,  or  the  acid  of  apples,  in  its  concentrated  state,  acts 
also  promptly  upon  the  teeth. 

"Muriatic,  sulphuric,  and  nitric  acids,  though  largely  diluted, 
soon  decompose  the  teeth.     These  are  in  common  use  as  tonics. 


THE   GUMS  AND    THEIR   DISEASES.  291 

"  Sulphuric  and  nitric  ethers  have  a  similar  deleterious  effect,  as 
also  spirits  of  nitre.  These  are  common  diffusible  stimulants  in 
sickness. 

"  Supertartrate  of  potash  destroyed  the  enamel  very  readily.  This 
article  is  frequently  used  to  form  an  acidulated  beverage. 

"Raisins  so  corroded  the  enamel  in  twenty-four  hours  that  its 
surface  presented  the  appearance,  and  was  of  the  consistency,  of 
chalk. 

"  Sugar  had  no  effect  till  after  acetous  acid  was  formed,  but  then 
the  effect  was  the  same  as  from  this  acid  directly  applied." 

A  very  common  cause  of  ulitis  in  persons  with  carious  teeth  re- 
sults from  the  too  free  use  of  creasote.  This  agent,  used  pure,  is  a 
powerful  irritant,  and  has  been  the  cause  of  some  of  the  most  severe 
acute  inflammations.  Seen  early,  the  cases  exhibit  the  direct  effect 
of  the  agent  in  the  escharotic  result  that  has  been  produced  on  the 
mucous  membrane, — this  being  white,  pasty,  and  sloughing.  Out- 
side of  the  immediate  local  use  of  oil  or  butter,  if  it  is  inferred  that 
free  creasote  remains  about  the  mouth,  such  cases  are  to  be  treated 
on  common  principles.  A  case  occurred,  some  short  time  back,  in 
my  own  practice,  where  a  girl,  with  an  intent  to  commit  suicide, 
swallowed  two  drachms  of  the  agent.  Called  immediately,  I  used 
as  an  emetic  the  first  thing  at  hand,  namely,  the  soap  on  her  wash- 
stand,  and  followed  the  emetic  with  half  a  pound  of  common  table- 
butter.  No  particular  bad  results  occurred  ;  the  patient  had  a  more 
or  less  sore  mouth,  oesophagus,  and  stomach  for  three  days,  after 
which  she  seemed  about  as  usual. 

Chloride  of  zinc,  used  in  the  mixing  of  the  so-called  bone  plugs 
now  so  freely  employed  in  dental  surgery,  is  another  of  the  causes 
of  ulitis.  Its  action  may  be  of  a  twofold  character :  either  directly 
upon  the  gum  tissue,  as  by  its  careless  use  it  is  allowed  to  come  in 
contact  with  it,  or  through  a  periodontitis  excited  by  the  action  of 
the  agent  on  the  dental  pulp.  From  this  cause,  cases  occur  in 
which  large  portions  of  the  gums  are  destroyed ;  and  not  unfre- 
quently  the  action  extends  to  the  alveolar  process,  necrosing  the 
sockets  of  the  teeth. 

A  cause  of  chronic  ulitis,  which  has  been  occasionally  met  with, 
consists  in  a  wedge  of  gold  or  other  metal  forced  into  the  dental  pit 
by  the  dentist,  while  in  the  act  of  filling  a  tooth  on  its  approximal 
face.  A  matter  of  this  kind  is  very  apt  to  be  overlooked  by  the 
general  practitioner,  hence  an  unappreciated  stubbornness  in  his  case. 
When  ulitis  is  circumscribed,  and  the  center  of  the  trouble  seems  to 


292  ORAL  DISEASES  AXD  SURGERY. 

be  a  tooth  filled  on  an  approxinial  surface,  attention  may  be  first 
directed  to  such  condition.  Let  the  practitioner  take  a  strand  of 
common  ligature  silk,  and,  passing  it  between  the  teeth,  feel  if  it 
runs  freely  about  the  necks ;  if  it  should  catch,  the  probability  is  he 
has  discovered  the  trouble. 

The  too  free  use  of  arsenical  paste  in  the  destruction  of  the  dental 
pulp  is  a  frequent  source  of  utilis.  I  have  seen  two  or  three  very 
severe  cases  from  such  a  cau.se.  In  the  use  of  this  remedy,  it 
is  in  every  instance  well  to  cover  it  in  the  cavity  with  a  particle 
of  wax,  or  where  this  is  not  admissible  (and  there  are  certainly  cases 
enou"h  where  it  is  quite  impossible),  then  a  tuft  of  cotton,  satu- 
rated with  gum  sandarac,  is  placed  over  the  application,  and  pro- 
tected for  a  few  moments  until  it  hardens.  In  inflammation  from  this 
cause  the  immediate  local  use  of  the  sesquioxide  of  iron  has  been 
recommended ;  but,  personally,  I  have  seen  no  good  results  from 
it,  the  harm  being  done  before  the  patient  applies.  Syringing  the 
parts  thoroughly,  and  a  treatment  directed  on  general  principles,  is 
all  that  can  be  done. 

Brushes  used  in  cleansing  the  teeth,  from  their  over-stififness,  are 
frequently  a  source  of  offense,  really  tearing  the  epithelium  at  each 
cleansing,  from  the  mucous  membrane ;  the  patient  complains  of  the 
soreness  and  bleeding  of  the  gums  every  time  the  teeth  are  brushed, 
yet  seems  to  fail  in  recognizing  that  he  himself  produces  the  trouble. 

9th.  Improperly  inserted  Artificial  Teeth. — Ulitis,  resulting  in 
fungoid  degeneration,  and  in  the  most  troublesome  of  chronic  con- 
ditions, is  frequently  witnessed  as  the  result  of  ill-adapted  den- 
tures and  of  unsuitable  material  employed  in  their  construction. 
Teeth  inserted  on  plates  held  in  position  by  clasps  or  bands  attached 
to  certain  teeth,  are  a  prolific  source  of  offense.  Where  the  bearings 
of  a  plate  are  not  accurate,  the  bands  cut  into  the  gum,  fret  and 
irritate  them,  until,  in  the  end,  the  teeth  to  which  the  clasps  are  at- 
tached are  loosened,  the  gum  passes  to  a  chronic  degeneracy,  puffs  up, 
losing  much  of  its  vitality ;  otherwise  a  hypertrophied  ring  of  the 
tissue,  hard  and  callosed,  surrounds  the  diseased  tooth,  and  serves 
as  a  sort  of  protection  to  the  adjoining  parts.  A  case  just  now 
comes  to  my  mind  in  which  a  lady,  wearing  an  upper  set  of  teeth, 
supported  partially  by  atmospheric  pressure  and  partly  by  a  band 
passing  around  the  only  natural  tooth  in  her  mouth,  had  provoked, 
in  this  socket,  an  epulo-fungoid  growth  of  such  threatening  character 
that,  failing  to  cure  it  by  ordinary  means,  I  felt  compelled  to  ad- 
vise an  operation  as  the  only  hope  of  saving  her  life.     Epithelioma 


THE  GUMS  AND   THEIR   DISEASES.  293 

I  have  also  seen  located  by  a  similar  cause  ;  having,  in  my  own  prac- 
tice, the  misfortune  to  lose  one  such  case.  In  Mr.  Heath's  Jack- 
sonian  prize  essay,  drawings  are  given  of  certain  papular  hypertro- 
phies (thought  by  the  author  to  be  quite  rare  specimens)  on  the 
oral  mucous  membrane.  These  hypertrophies  I  have  frequentlv 
seen  on  the  membrane  beneath  the  cavities  of  suction  plates ;  thev 
look  like  enlarged  and  indurated  fungiform  papillae.  Another  form 
of  such  hypertrophy  is  induration  of  the  membrane  in  full,  lying  be- 
neath the  cavity;  the  parts  are  raised  by  subeffusions,  which  organ- 
ize and  become  as  hard  almost  as  cartilage.  Still  another  form  is 
the  rugose — several  wheels  running  across  the  space ;  these  indura- 
tions I  have  never  known  do  any  harm.  In  some  instances  they 
remain  permanent  after  the  removal  of  the  offense;  but,  as  a  rule, 
they  will  be  found  to  disappear  in  a  few  months  after  a  plate  is 
taken  away.  Indeed,  I  met  one  lady  having  these  hypertrophied 
papillae,  who  told  me  she  had  had  them  for  over  a  year,  and  had 
never  ceased  to  wear  her  plate. 

Hypertrophy  of  the  gum  in  mass  occasionally  results  from  the 
mechanical  irritation  of  dental  plates.  I  am,  at  the  time  of  writing 
this,  treating  a  lady  suffering  under  such  an  enlargement ;  the  trou- 
ble is  in  the  upper  gums,  and  they  seem  like  thickened  masses  of 
gristle,  and,  I  am  sorry  to  say,  prove  about  as  insensible  to  medici- 
nal impressions. 

Yulcanite,  a  material  much  employed  in  the  construction  of  dental 
plates,  is,  to  many  mouths,  a  source  of  unbearable  offense.  The 
cases  that  have  come  under  my  own  observation  have  been  all  alike, 
— soft,  flabby,  relaxed,  congested,  and  very  sluggish  in  recuperation, 
— the  gum  tissue  seeming  to  be  softened  from  surface  to  base.  Acid 
and  astringent  lotions  are  best  adapted  to  the  cure. 

Silver  is  another  material  that  it  would,  perhaps,  be  as  well  to  dis- 
pense with  in  the  construction  of  dental  appliances ;  also  gold  too 
much  alloyed  with  copper,  running  down,  as  it  is  sometimes  found, 
to  fourteen  carats. 

10th,  1 1th.  In  other  parts  of  this  work  I  take  occasion  to  treat, 
under  what  is  deemed  to  be  proper  heads,  various  conditions,  com- 
monly associated  under  the  common  appellation  of  gum  diseases,  as, 
for  example,  the  epuHc  growths  considered  in  succeeding  chapters. 

Observation  of  Fig.  61  exhibits  a  congestion  which  has  swollen 
the  gums  and  tissues  of  the  hard  palate  to  an  extent  which  conceals 
almost  completely  three  posterior  teeth  which  remain  in  the  parts. 


294  ORAL  DISEASES  AND  SURGERY, 

The  patient,  from  whose  mouth  the  drawing  was  made,  had  worn 
a  plate  of  vulcanite  nine  months ;  the  parts  were  a  dusky  red, — flabby, 
relaxed,  and  exceedingly  indolent.  There  was  no  particular  complaint 
of  pain, simply  a  soreness,  together  with  a  tenderness  on  pressure, 

Fio.  Gl. View  of  Gums  Inflamed  by  Vulcanite  P;.ate. 


which  gradually  had  increased  until  the  removal  of  the  piece  became 
a  necessity.  The  cause  of  irritation  from  these  plates  is  variously 
considered  :  the  most  likely,  however,  of  which  is  the  very  complete 
exclusion  of  atmospheric  air,  and  the  consequent  heating  which  fol- 
lows. To  cure  such  cases  it  will  be  found,  in  most  instances,  a  ne- 
cessity to  remove  the  denture,  after  which  stimulating  and  astringent 
gargles  may  be  prescribed.  A  wash,  used  in  the  particular  case 
above  described,  which  acted  to  entire  satisfaction,  was  compounded 
as  follows  : 

B. — Aqua  Cologn.  ^i ; 

Tinct.  capsici  comp.  5i ; 

Sodae  boras,  5y  ; 

Tinct.  cinchonje,  ^ij  ; 

Tinct.  pyrethri,  Ji ; 

Aqua,  ^iij.     M. 

Cases  of  hypertrophy  from  ill-fitting  clasps  or  ill-fitting  plates  are 
not  unfrequently  met  with  ;  sometimes  such  an  induration  will  be 
found  circumscribing  a  single  tooth  to  an  extent  which  half  conceals 
it,  the  band  being  accommodated  in  a  space  existing  between  the 
gum  and  tooth.  I  have  known  such  cases  to  give  much  concern  by 
the  obstinacy  of  their  persistence  after  the  removal  of  the  cause  of 
oflFense ;  but  such  anxiety  is  seldom  well  founded,  for  even  should 
the  induration  remain  it  will  exhibit  no  tendency  to  degenerate.  In 
the  treatment  it  is  only  desirable  to  remove  the  offending  band,  and 
leave  the  case  to  nature. 


THE    GUMS  AND    THEIR   DISEASES.  295 

As  general  hypertrophy  of  the  gums  is  concerned,  I  might  illus- 
trate the  condition  by  referring  to  a  case  at  present  under  treatment. 
The  patient,  a  lady  in  fine  health,  middle  aged,  wears  a  plate  of  gold 
containing  seven  scattered  teeth.  Wherever  this  plate  bears,  the 
parts  are  enlarged,  indurated,  and  scirrhus-like.  If  it  were  not  for 
the  absence  of  the  peculiar  pain  of  carcinoma  one  might  very  readily 
infer  the  presence  of  such  disease.  The  only  explanation  of  such 
induration  is  to  be  found  in  the  imperfect  adaptation  of  the  denture, 
conjoined,  perhaps,  with  a  cachexia.  The  treatment  has  been  the 
very  simple  one  of  advising  the  patient  not  to  wear  the  plate,  nor 
any  other,  until  a  cure  is  obtained.  No  medication  has  been  deemed 
necessary. 

Still  another  class  of  cases  exists  in  the  hypertrophy  of  the  mucous 
membrane  lying  beneath  the  surface  of  suction  cavities.  Sometimes 
this  surface  will  be  found  simply  thickened  and  hardened ;  at  other 
times  it  will  be  seen  broken  into  deep  fissures;  still  again  it  is 
observed  studded  with  papillae,  fungiform  in  character,  and  not  un- 
frequently  possessed  of  a  tendency  to  hemorrhage.  I  have  met  with 
these  various  cases  where  quite  serious  results  seemed  threatened, 
although  but  in  a  single  one  did  ever  any  ill  consequences  ensue.  In 
this  one  case  necrosis  of  the  underlying  bone  exposed  the  nares. 

Treatment. — This  is  generally  to  be  tentative;  the  plate  must 
be  removed,  or  at  least  the  suction  cavity  must.  If  the  parts  do  not 
recover  after  such  removal  of  the  oifense,  it  may  be  found  desirable 
to  touch  with  zinc,  iodine,  or  capsicum.  If  caries  or  necrosis  should 
ensue,  such  conditions  are  to  be  treated  as  referred  to  in  the  chapter 
on  these  diseases. 

Fig.  62. — View  of  Case  of  Congenital  Hypertrophy. 


An  interesting  case  exhibited  in  the  cut,  markedly  illustrative  of 
the   condition,  is   described  in  Professor  Gross's  System  of  Sur- 


296  ORAL  DISEASES  AND  SURGERY. 

gcry:  "The  gum  of  the  upper  jaw  formed  a  tumor  of  a'  pale 
color,  inelastic,  perfectly  insensible,  and  of  firm  consistence,  pre- 
senting very  much  the  appearance  of  the  snout  of  a  hog.  It  was 
rouo-h  on  the  surface,  and  was  about  an  inch  and  a  quarter  in  its 
antero-posterior  diameter,  its  width  having  been  about  one  inch  and 
a  half.  At  its  free  margin,  which  was  quite  irregular,  was  seen  the 
tip  of  the  left  central  incisor.  Extending  back  from  this  tumor,  on 
each  side  of  the  whole  length  of  the  jaw,  was  the  enlarged  gum, 
forming  a  thick,  broad  ridge,  completely  imbedding  the  teeth.  At 
several  points,  particularly  behind,  the  morbid  growth  was  more 
than  nine  lines  in  width ;  in  front,  and  at  the  middle,  it  was  less. 
It  was  of  a  more  florid  color  than  the  main  tumor,  but  of  about  the 
same  degree  of  consistence.  Opposite  the  bicuspid  teeth  on  each 
side,  it  exhibited  a  remarkably  granulated  appearance,  the  excres- 
cences having  a  pediculated  form,  and  being  folded  upon  each  other. 
Projecting  toward  the  I'oof  of  the  mouth,  it  greatly  encroached  upon 
this  cavity,  lessening  its  capacity,  and  thus  interfering  with  its  func- 
tion, as  well  with  speech  and  respiration. 

"  The  lower  gum  was  in  the  same  condition  as  the  upper,  being 
equally  hard  and  insensible,  but  less  developed.  It  was  of  a  bluish, 
florid  complexion,  and  larger  in  front  and  behind  than  at  the  inter- 
mediate points  ;  its  free  surface  was  uneven,  and  so  prominent  as  to 
hide  all  the  teeth,  except  the  central  incisors,  the  point  of  the  right 
cuspid,  and  the  cusps  of  each  deciduous  and  first  permanent 
molars." 

The  treatment  in  this  case  consisted  of  thorough  removal  by  means 
of  scalpels  and  scaling  instruments.  A  good  deal  of  blood  was  lost, 
and  the  operation,  which  had  to  be  several  times  repeated,  was 
necessarily  tedious.  Professor  Gross  remarks  that  Dr.  J.  N.  M. 
Lynch,  whose  patient  the  boy  was,  informed  him  four  years  after 
the  operation,  that  the  condition  was  returning,  and  that  it  was  ac- 
companied with  marked  disease  of  the  heart,  with  considerable 
enlargement  of  the  tonsils,  arches  of  the  palate,  and  the  papillae  of 
the  tongue. 

Fig.  C3,  a  case  of  chronic  ulitis,  with  recession,  is  a  type  of  a  most 
common  condition,  and  has  a  great  variety  of  meanings.  The  prin- 
cipal cause  of  such  recession  is  found,  however,  according  to  my 
own  experience,  in  the  accumulation  of  small  quantities  of  tartar 
just  below  the  free  edge  of  the  gums.  A  second  cause,  and  a  very 
prominent  one,  lies  in  a  solidification  of  the  tooth  structure,— the 


THE   GUMS  AND    THEIR  DISEASES. 


297 


equilibrium  of  circulation  existing  between  the  tooth  pulp,  perios- 
teum, and  gum  being  thus  distui'bed.  Causes  strictly  local,  how- 
ever, need  only  concern,  as  the  appearance  of  the  parts  and  the 
health  of  the  teeth  are  concerned ;  they  are  susceptible  of  remedy, 
needing  only  attention  and  the  proper  skill.  It  will  be  readily 
inferred,  from  what  has  been  said  on  previous  pages,  that  local 
lesions  are  not  alone  to  blame  for  such  conditions.  "  In  forming 
a  judgment,"  says  Mr.  Bell,  "  upon  eases  of  this  description,  and 
even  upon  those  in  which  the  loss  of  substance  is  associated  with 
more  or  less  of  diseased  action,  it  is  necessary  to  recollect  that  the 

Fig.  63. — View  of  Chronic  Ulitis,  with  Eecession. 


teeth  in  old  age  are  removed  by  this  identical  process,  namely,  the 
destruction  of  their  support  by  the  absorption  of  the  gums  and 
alveolar  processes ;  and  as  this  step  toward  general  decay  com- 
mences at  very  different  periods  in  different  constitutions,  it  may, 
doubtless,  in  many  cases,  even  in  persons  not  beyond  the  middle 
period  of  life,  be  considered  as  an  indication  of  a  sort  of  premature 
old  age,  or  an  anticipation  at  least,  of  senile  decay,  as  far  as  regards 
these  parts  of  the  body." 

In  depressed  conditions  of  the  life  force,  as  witnessed  in  the 
habitual  drinker  and  debauchee,  such  recession  is  generally  found 
conjoined  with  suppuration,  and  affects  all  the  parts  alike;  the  gums 
are  turgid,  sluggish-looking,  and  more  or  less  purple ;  the  mucous 


298  ORAL  DISEASES  AND  SURGERY. 

membrane  lining  the  mouth  and  throat  is  a  dirtj  red  ;  the  tremor 
and  prostration  of  the  system  at  large  show  the  constitutional 
nature  of  the  offense. 

Another  form  of  this  recession  is  associated  with  the  sickly  and 
weak;  here,  however,  the  part  is  even  lighter  than  in  health,  is 
shriveled  and  shrunken,  clasping  the  neck  of  the  tooth  tightly  and 
closely, — seeming,  indeed,  shrinking  within  itself.  These  cases  are 
always  anaemic,  being  found  usually  in  the  female  sex,  or  in  males  in- 
clining to  phthisis.  In  short,  as  remarked  by  Dr.  Harris,  "  every  dis- 
ease of  the  general  system  tending  to  increase  the  susceptibility  of 
the  gums  to  the  action  of  local  irritants  favor  the  production  of  the 
condition."  Everything  that  tends  to  induce  such  conditions  may  be 
regarded  as  predisposing  causes :  such  are  bilious  and  inflammatory 
fevers,  the  excessive  use  of  mercurial  medicines,  the  venereal  virus, 
any  and  everything  tending  to  the  deterioration  of  the  fluids  of  the 
body.  Persons  of  cachectic  habit  are  far  more  subject  to  it,  and 
generally  in  its  worse  forms,  than  those  individuals  in  the  enjoyment 
of  good  health.  Because  of  the  truthfulness  of  such  assumptions  it 
is  seen  that  the  condition  is  an  occasion  of  warning.  In  my  own 
experience  I  have  not  unfrequently  recognized  that  such  a  recession 
of  the  guTus  was  a  first  indication  of  a  finally  destructive  disease. 

Treatment. — This  is  of  course  to  be  directed  to  the  cause.  Where 
this  shall  be  found  to  be  of  a  strictly  local  nature,  most  excellent 
effects  are  occasionally  secured  by  scarifying  the  affected  gums  three 
or  four  times  a  week,  and  touching  them  lightly  with  chloride  of  zinc, 
a  solution  in  strength  of  about  grs.  xx  to  water  ^i.  Sometimes,  and 
I  have  occasionally  succeeded  much  to  my  satisfaction,  the  edges  may 
be  pared  and  brought  together  with  a  single  stitch ;  this  little  opera- 
tion, however,  only  applies  where  the  tissues  are  reasonably  loose 
and  fairly  healthy,  and  the  recession  is  Y-shaped.  Compound 
tincture  of  capsicum  is  an  excellent  provocative  of  granulations. 
Iodine  also  acts  happily,  but  it  should  not  be  allowed  to  touch  the 
teeth, — the  parts  are  always  to  be  scarified  to  allow  such  applications 
to  be  of  any  service.  The  various  washes  recommended  are,  of 
course,  useful  or  not  so,  according  as  they  may  be  adapted  to  the 
peculiar  indications ;  of  these,  the  stimulating  and  astringent  will  be 
found  most  frequently  demanded.  Where  the  teeth  are  thus  exposed 
without  apparent  lesion,  either  of  a  local  or  general  nature,  the 
trouble  is  to  be  esteemed  as  incurable. 

Congenital  Union  of  Gums.— Br.  W.  S  Carter  reports  the  follow- 
ing anomalous  case,  which,  with  a  few  others,  we  present  as  in- 


THE  GUMS  AND    THEIR    DISEASES.  299 

I  teresting  studies  in  this  direction  of  oral  troubles :  "  Mrs.  W.  was 
delivered,  after  an  easy  labor  at  full  term,  of  a  living  male  child. 
The  infant  was  perfectly  quiet  for  a  few  moments  after  its  birth,  and 
then  spasmodic  respiratory  efforts  were  made.  Thinking  the  throat 
might  be  obstructed  by  mucus,  I  endeavored  to  introduce  my  finger 
to  remove  it.  The  finger  passed  readily  between  the  lips,  but  to  my 
astonishment  I  could  get  it  no  further  than  the  gums,  which  both  by 
sight  and  touch  I  found  firmly  united. 

"  As  it  was  necessary  to  act  promptly,  I  immediately,  with  the 
assistance  of  my  partner,  Dr.  Tilford,  divided  the  tissue  uniting  the 
gums.  This  appeared  to  be  about  as  thick  as  the  gums,  and  was 
cartilaginous,  extending  as  far  back  on  either  side  as  the  angle  of  the 
jaw.  Notwithstanding  this  free  division,  which  enabled  the  child  to 
breathe  with  more  facility,  the  jaws  were  immovable. 

"After  letting  the  patient  rest  a  few  hours.  Dr.  Sellers,  of  Browns- 
burg,  visited  the  patient  with  me ;  and  it  was  decided  to  use  some 
force  to  separate  the  jaws,  and  make  a  further  careful  exploration. 
This  exploration  showed  us  a  tough  membrane,  one-eighth  of  an 
inch  in  thickness,  passing  from  the  palate  bone  above,  and  inserted 
into  the  lower  gum.  Upon  the  division  of  this  and  the  use  of  some 
little  force,  the  jaws  were  separated. 

"  In  two  weeks  the  gums  had  healed,  the  child  took  nourishment 
readily,  and  was  doing  well. 

"  Other  malformations  also  existed  in  this  case,  viz.:  the  fingers 
and  toes  were  webbed,  and  the  ears  were  in  rather  a  rudimentary 
condition — the  integument  passing  from  the  head  over  the  anterior 
surface  of  the  upper  third  of  each  of  these. 

"  When  the  mother  was  about  three  months  pregnant,  her  son, 
about  six  years  of  age,  had  a  severe  convulsion,  the  jaws  being  spas- 
modically closed.  She  was  alone  at  the  time,  and  her  terror  was 
excessive;  and,  indeed,  since  then,  during  all  the  remaining  months 
of  her  pregnancy,  she  states  the  frightful  scene  has  scarcely  ever 
been  absent  from  her  mind." 

"We  have  delayed,"  remarks  the  editor  in  whose  journal  this  in- 
teresting communication  appears,  "for  some  weeks  the  publication  of 
Dr.  Carter's  extraordinary  case,  in  order  that  we  might,  if  possible, 
find  recorded  some  similar  cases  or  case ;  but  after  a  diligent  search 
we  have  been  utterly  disappointed.  Even  Saint-Hilaire,  to  whose 
study  of  the  various  anomalies  of  organization  science  is  so  greatly 
indebted,  fails  us  in  presenting  any  analogous  instance. 

"While  almost  any  one  of  the  external  openings  of  the  body  may 


300  ORAL  DISEASES  AND  SURGERY. 

be  imperforate,  yet  this  condition  much  oftener  affects  the  inferior 
than  the  superior  orifices  of  the  trunk — e.g.  closure  of  the  anus  as 
a  cono-enital  condition  is  more  frequently  met  with  than  closure 
of  the  eyelids,  closure  of  the  vagina  than  of  the  external  auditory 
meatus. 

"  In  rc'-'ard  to  congenital  adhesions  of  the  mouth  hitherto  de- 
scribed, they  have  been  from  adherence,  sometimes  complete,  in 
other  instances  partial,  of  the  lips.  Even  this  malformation  the 
illu-strious  Boyer  spoke  of  as  a  possibility,  never  having  seen  it;  but 
Yelpeau  discovered  that  Haller  had  pointed  out  its  occurrence  in  the 
human  species  and  also  in  the  inferior  animals,  that  Schenkius  had 
met  with  cases  upon  which  he  had  to  operate,  and  that  Desgenettes 
had  seen  a  seven  months'  foetus  with  imperforate  mouth. 

"In  Saint-Hilaire's  work,  chapter  iii.,  Bes  Anomalies  2^o,r  con- 
tinuite  des  parties  ordinairement  disjointes,  section  i.,  Des  Anoma- 
lies par  Imperforation,  will  be  found  the  following,  which  may  be 
of  some  interest  in  connection  with  Dr.  Carter's  report :  The  imper- 
foration of  the  nares  is  much  less  frequent  than  that  of  the  eyelids ; 
nevertheless,  Littre  and  Jean  Bianchi  have  seen  it  in  subjects  in 
whom  other  irregularities  also  were  found,  and  Oberteuffer  has  also 
several  times  observed  the  same  condition. 

"  In  the  case  mentioned  by  Littre,  the  closure  of  the  nares  was 
complicated  with  closure  of  the  mouth,  the  skin  passing  over  both 
apertures,  an  anomaly  of  still  less  frequent  occurrence.  The  closure 
of  the  mouth  has  also  been  seen  where  the  nares  were  unobstructed, 
but  these  cases  presented  various  other  deviations  also. 

"  As  to  the  possible  influence  of  the  sudden  and  severe  terror  to 
which  the  mother  was  subjected,  which  Dr.  Carter  mentions,  in  caus- 
ing the  malformation,  it  probably  is  better  neither  to  affirm  nor,  still 
less,  to  deny.  Certain  it  is  that  the  tendency  of  the  observant  and 
thoughtful  in  our  profession  is,  not  to  reject  as  '  old  wives'  fables' 
all  that  is  told  us  of  the  very  strong  influence  of  maternal  impres- 
sions upon  the  foetus,  fables  which  have  so  long  found  such  general 
credence  with  mothers  and  with  the  public.  Those  who  are  inter- 
ested in  the  study  of  this  question  will  find  an  admirable  and  philo- 
sophic discussion  of  it,  by  Dr.  Alfred  Meadows,  in  the  seventh  volume 
of  the  London  Obstetrical  Society^s  Transactions.  It  occurs  in  con- 
nection with  the  report  of  a  case  of  Monstrosity,  given  by  Dr.  M., 
the  mother  attributing  the  deformities  of  her  offspring  to  the  fact 
that  during  the  earlier  weeks  of  her  pregnancy  she  was  greatly  hor- 
rified by  being  shown  some  of  Aristotle's  plates,  in  which  were  ex- 


THE   GUMS  AND    THEIR   DISEASES.  301 

hibited  some  deformities  resembling  this,  and  specimens  of  other 
monstrosities." — (Western  Journ.  of  Medicine.) 

"  Stomatilis  and  Pharyngitis  Leucaemica. — In  Virchowh  Ar- 
chives, Dr.  F.  Hosier  relates  the  case  of  a  male  40  years  old,  and 
previously  of  sound  health,  in  whom,  in  the  course  of  some  fifteen 
months,  there  took  place  gradually  a  swelling  of  the  glands  on  both 
sides  of  the  throat,  attended  with  inflammation  of  the  mucous  mem- 
brane of  the  mouth  and  pharynx,  with  flaccidity  of  and  hemorrhage 
from  the  gums,  followed  by  swelling  of  the  axillary  and  inguinal 
glands,  and  finally  of  the  liver  and  spleen.  There  was  now  an  evi- 
dent increase  in  the  white  particles  of  the  blood.  In  the  case  de- 
scribed, the  only  etiological  agent  to  which  the  morbid  phenomena 
it  presented  could  be  referred  was  inordinate  exertion  of  mind  and 
body.  The  condition  of  the  throat  was  of  especial  interest.  Its 
mucous  membrane  was  red  and  swollen,  and  over  its  surface  there 
were  spread  numerous  medullary  elevations  having  a  smooth  shining 
appearance.  Both  tonsils  were  enlarged,  and  their  surfaces  pre- 
sented the  appearance  of  a  congeries  of  large,  dense,  medullary 
knots.  The  secretions  of  the  surface  of  the  mouth  and  larynx  and 
of  the  salivary  glands  were  greatly  increased  by  talking.  After  a 
thorough  rinsing  of  the  mouth,  its  secretions  gave  an  acid  reaction. 
The  patient  had  not  suffered  previously  from  any  disease  of  the 
mouth  or  throat.  The  patient  was  attacked  with  this  only  after  the 
lymphatic  glands  of  the  neck  had  become  enlarged,  and  at  first,  with 
their  increase  or  diminution  the  throat  affection  became  worse  or  bet- 
ter. Finally,  under  the  use  of  quinia  and  iron,  remedies  which  exerted 
a  beneficial  influence  on  the  entire  morbid  phenomena,  the  patient  got 
well.  Dr.  M.  believes  that  the  form  of  stomatitis  and  pharyngitis 
here  described  is  a  specific  disease  resulting  from  a  leucsemic  dys- 
crasy.  The  inflammation  of  the  mouth,  which  in  its  symptoms  had 
a  close  resemblance  to  scorbutic  stomatitis,  was  probably  caused  by 
au  irritation  due  to  some  morbid  chemical  product  in  the  blood  and 
the  secretions  of  the  lymphatic  glands,  by  which,  also,  according  to 
Dr.  M.,  is  to  be  explained  the  affection  of  the  mouth  met  with  in 
cases  of  diabetes,  the  nature  of  which  is  still,  however,  unknown." 

"Blue  Line  in  Saturnine  Affections,  and  its  Pathognomonic 
Value.  (Archives  de  Medecine  Navale,  and  Gazette  Hebdoma- 
daire.) — Dr.  Falot  refutes  the  authors  who  believe  that  the  blue  line 
along  the  gums  is  formed  by  an  accidental  deposit  on  the  buccal 
mucous  membrane  of  lead  furnished  by  dust  contained  in  the  air  or 
food,  or  still  more  in  fluids  that  have  been  adulterated  or  accident- 


302  ORAL  DISEASES  AND  SURGERY. 

ally  charged.  According  to  M.  Grisolle,  among  others,  the  blue  line 
is  the  livery  of  the  lead-worker,  not  a  symptom  of  poisoning,  but  a 
simple  deposit,  and  a  sign  of  the  worker's  occupation.  M.  Falot 
quotes  the  observations  of  Beau,  Barlow,  Gregory  Smith,  and  Le- 
coq,  all  of  whom  observed  the  blue  line  in  patients  undergoing  an 
internal  treatment  with  pills  of  subcarbonate  or  acetate  of  lead ;  and 
he  gives,  in  addition,  the  reports  of  some  cases  of  his  own,  which 
were  gathered  in  an  epidemic  of  colic  in  a  ship's  crew  at  the  Ga- 
boon, the  cause  of  which  was  lead-poisoning.  Finally,  after  having 
established  by  experiment  the  impossibility  of  reproducing  the  blue 
line  artificially  by  touching  the  gums  corresponding  to  the  incisor 
and  canine  teeth  of  the  lower  jaw  with  a  brush  dipped  in  acetate  of 
lead,  and  after  having  proved  that  oxygenated  water,  and  water 
sharpened  by  sulphuric  acid,  the  ordinary  reagents  of  lead,  had  no 
influence  upon  the  blue  line  when  it  is  plainly  established.  Dr. 
Falot  proves  that  the  line  is  the  result  of  an  elimination  of  the  lead, 
and  indicates  by  its  manifestation  that  the  lead,  carried  along  by  the 
circulation,  comes  to  be  deposited  in  the  tissue  of  the  gums,  where 
it  forms  a  combination  which  reveals  its  presence  by  a  more  or  less 
intense  blue  coloration.  M.  Falot  finishes  his  contribution  by  rep- 
resenting the  blue  line  as  a  sign  of  the  penetration  of  lead  into  the 
economy,  and  he  derives  the  important  conclusion  for  forensic  medi- 
cine, that  its  presence  may  denote  lead-poisoning,  although  an  analy- 
sis of  the  viscera  may  not  have  revealed  the  smallest  trace  of  the 
metal." 


CHAPTER    XX. 


CARIES   OF    THE    MAXILLA. 


Caries  of  bone  is  a  disease  most  analogous  to  ulceration  in  the 
soft  parts.  As  the  jaws  are  concerned,  it  is  confined  almost  ex- 
clusively to  the  superior  bones.  The  causes  inducing  this  condition 
are  of  course  various ;  yet  dead  teeth  and  roots  of  teeth  will  be 
found  far  to  preponderate. 

Caries  of  the  jaw  present  all  the  external  features  which  char- 
acterize the  ordinary  alveolar  abscess,  whether  in  its  acute  or  chronic 
forms.  This,  however,  would  be  inferred,  such  lesion  being  so 
commonly  its  origin.  When  the  attack  is  acute  in  its  nature,  ulitis 
or  periostitis  will  always  be  found  associated  with  it.  If  the  disease 
originates  as  a  pure  ostitis,  then  the  gum  in  turn  quickly  sympa- 
thizes ;  if,  on  the  contrary,  the  inflammation  arises  from  a  tooth, 
periodontitis  will  distinguish  the  offending  agent.  In  all  inflamma- 
tions about  these  parts,  whatever  their  character  and  cause,  the 
abortive  treatment  cannot  too  quickly  be  attempted.  From  failure 
to  attack  with  sufiScient  vigor  such  inflammations,  I  have  not  un- 
frequently  known  the  whole  bone  to  be  destroyed. 

Caries  once  established,  a  diagnosis  is  made  easy  through  the  in- 
strumentality of  the  sense  of  touch.  One  or  more  fistulous  openings 
will  be  found  to  exist  in  the  gum,  or  it  may  be  in  some  neighboring 
part ;  through  these  sinuses  it  is  only  necessary  to  carry  a  probe, 
when  the  bone  is  found  riddled,  honeycomb-like,  and  easy  to  break 
down.  In  such  examinations  it  always  will  be  found  advantageous 
to  replace  the  ordinary  probe  with  the  common  dental  excavator,  as 
otherwise,  from  the  less  accurate  touch  attained  through  the  first 
instrument,  it  may  be  possible  to  mistake  the  denuded  bone  of  ordi- 
nary alveolar  abscess  for  the  more  formidable  and  extensive  dis- 
ease. In  carrying  the  instrument  through  the  opening  of  an  alveolar 
abscess,  it  is  remarked  that  the  bone  is  denuded ;  but  the  touch  dif- 
fers from  that  present  in  caries,  in  the  fact  of  this  denuded  bone 
being  hard  and  resisting.  Not  always,  however,  for  it  has  been  just 
remarked  that  periodontitis  and  alveolar  abscess  are  the  most  com- 

(303) 


304  ORAL  DISEASES  AND  SURGERY. 

mon  cause  of  ostitis  and  caries,  reference  being  alone  had  to  the  i 
pure,  unconiplicatod  cases  of  alveolar  abscess.  As  a  rule,  when  a  , 
sharp  instrument  introduced  can  be  made  readily  to  pass  into  the  ' 
substance  of  the  bone,  and  to  break  it  down,  caries  is  present.  If,  ' 
on  the  contrary,  the  bone  is  solid  and  resisting,  even  although  found 
denuded,  caries  does  not  exist. 

An  ostitis,  however  provoked,  does  not  by  any  means  necessarily 
run  into  osseous  ulceration,  no  more  than  is  ulceration  necessarily  a 
result  of  an  inflammation  in  the  soft  parts.  There  are,  however, 
certain  individuals,  or  perhaps  it  is  better  to  say  conditions,  which 
markedly  predispose  to  such  ulcerations  ;  of  these  the  strumous  is 
without  doubt  the  most  marked.  The  bones  of  scrofulous  subjects 
break  down  easily,  also  persons  who  have  received  the  mercm'ial 
impression.  Cancerous  caries  of  the  upper  jaw  is  frequently  to  be 
met  with ;  while,  aside  from  such  conditions,  it  has  seemed  to  my 
experience  as  true,  that  in  persons  of  the  most  robust  and  vigorous 
health  a  slight  cause  has  been  suflBcient  to  develop  the  disease.  A 
case  this  moment  recalled  (a  very  marked  one)  will  serve  to  illus- 
trate the  probability. 

In  the  autumn  of  1867  a  gentleman  from  a  distant  State  visited 
Philadelphia  for  the  purpose  of  having  an  opinion  concerning  a 
flstule  that  existed  over  the  apex  of  the  right  upper  lateral  incisor 
tooth  which  had  long  resisted  the  ordinary  applications  and  injec- 
tions used  by  his  professional  adviser  at  home.  This  fistule  had 
originated  from  the  lateral  tooth,  which  was  a  dead  one,  and  was  con- 
sidered simply  an  alveolar  abscess  ;  the  only  question  thought  to 
be  involved  being  the  loss  of  the  tooth,  which  the  patient  was  most 
desirous  to  save.  The  gentleman  coming  first  under  the  care  of  a 
personal  friend,  I  had  an  opportunity  to  see  him  in  consultation, 
when  a  thorough  examination  revealed  a  softened,  honeycomb-like 
character,  not  only  of  the  right,  but  also  partially  of  the  left  jaw, 
necessitating  an  operation  of  very  extensive  character,  so  far  as  the 
removal  of  softened  bone  was  concerned. 

In  this  case  I  failed  to  recognize  anything  wrong  with  the  gen- 
eral health  of  the  patient,  in  Avhich  opinion  I  was  joined  by  his 
professional  adviser;  the  person  being  young,  and  of  more  than 
commonly  vigorous  habits.  The  primary  lesion  was,  without  doubt, 
the  dead  lateral  incisor.  Why  it  should  have  provoked  such  exten- 
sive disease  one  is  at  a  loss  to  say. 

In  this,  as  in  many  cases,  the  disease  was  developed,  and  ad- 
vanced without  any  very  marked  acute  manifestations,  a  not  un- 


CARIES   OF   THE   MAXILLM.  305 

common  feature  in  caries,  and  one  which  is  of  much  importance  to 
be  borne  in  mind.  A  whole  jaw  may  be  softened  and  destroyed, 
while  the  patient  rests  under  the  false  impression  that  he  has  no 
trouble  that  is  beyond  cure  through  the  loss  of  a  tooth.  I  have 
occasionally  met  with  cases  of  this  kind,  where  even  the  physician 
has  been  alike  deceived. 

The  slowness  or  the  rapidity  with  which  caries  progresses  is  in- 
fluenced by  individual  conditions.  Thus,  in  the  periods  of  dentition, 
it  will  commonly  be  found  to  have  rapid  progress,  unless,  indeed, 
the  vital  forces  are  very  resisting ;  while  in  the  mercurially  weakened 
bone  caries  seems  sometimes  analogous  to  a  simple  mechanical  dis- 
integration, as  if,  indeed,  the  particles  of  bone  had  lost  the  power 
of  cohesion. 

The  peculiar  affinity  existing  between  this  disease  and  the  cellular 
tissue  of  the  bones  leads  to  the  inference  that  it  is  more  common  to 
persons  whose  skeletons  are  loose  and  spongy  in  character  than  to 
the  reverse  class, — and  this  is  markedly  true ;  hence  strumous 
children  are  very  subject  to  caries,  as  is  so  often  witnessed  in  their 
articular  complaints. 

In  many  subjects  the  condition  seems  to  be  that  of  a  semi- 
fatty  degeneration,  the  animal  portion  of  the  bone  becoming  quite 
soft  and  greasy ;  indeed,  even  the  osseous  particles  thrown  oif 
present  the  same  aspect.  The  relationship  of  the  disease  with 
tubercular  deposits  is  so  fully  established  in  the  minds  of  many 
that  they  incline  to  the  conviction  that  such  tubercle  is  present  at 
any  and  all  points  of  the  manifestation  of  caries.  That  this,  how- 
ever, is  not  fully  true,  is  affirmed  by  examples  such  as  have  been 
alluded  to.  That  constitutional  causes  have,  however,  much  more 
to  do  with  the  development  of  caries  than  local  injuries,  is  suffi- 
ciently evident  in  the  immunity  of  the  numberless  persons  who 
have  been  brought,  without  ill  result,  under  the  influences  of  similar 
local  sources  of  irritation. 

It  has  been  suggested  that  caries  may  exhibit  itself  in  various 
ways.  Yet,  however  and  whatever  the  manifestation,  an  ostitis 
must  precede  the  ulcei'ation.  About  the  jaws  the  great  majority  of 
cases  have,  in  their  incipiency,  nothing  to  distinguish  them  from 
ordinary  periodontitis;  and  it  is  by  far  most  frequently  the  case  that 
the  acute  attack  has  been  long  past  before  this  peculiar  ulceration  is 
developed,  it  seeming  to  be  that  the  resistive  power  of  the  bone  is 
gradually  worn  out  by  the  presence  of  chronicity  ;  the  inflamed 
tooth  has  died,  and  its  devitalization  is  the  source  of  ofiense.    Nearly 

20 


306  ORAL  DISEASES  AND   SURGERY. 

every  case  of  caries  of  the  jaws  that  I  have  seen  could  have  been 
aborted  by  the  timely  removal  of  a  certain  tooth  or  teeth — not  of 

course  all but  that  great  majority  which   have  had  the  exciting 

cause  of  dental  irritation. 

A  carious  bone  presents  peculiarities  according  to  the  duration 
of  the  disease  and  the  several  phases  of  causes  inducing  it.  If 
seen  early,  there  is  to  be  observed  simply  the  increased  vascularity 
and  cono-ostion  of  the  inflammation.  A  little  later,  and  a  caco- 
plastic  exudate  occupies  the  cells,  which,  in  their  turn,  have  become 
enlarged,  and  their  walls  softened ;  these,  still  later,  commence  grad- 
ually to  break  down,  together  with  the  semi-organized  lymph  ex- 
uded into  them ;  in  proportion  as  such  exudation  has  been,  and  is, 
extensive,  and  the  breaking  down  is  rapid,  so  the  caries  may  be 
said  to  be  dry  or  moist ;  such  exudation  and  degeneration  are 
markedly  exhibited  in  many  cases  of  hip  disease,  or  white  swelling 
of  the  knee-joint,  where  the  discharge  may  amount  to  quite  as  much 
as  a  pint  a  day.  In  now  looking  at  the  bone,  we  find  it  riddled  with 
irregular  cavities,  many,  or  all,  of  which  are  lined  by  a  sort  of  im- 
perfect secretory  membrane,  or  perhaps  it  would  be  more  correct  to 
say,  a  glazing  of  organized  exudate  corpuscles.  If  the  disease  is  to 
involve  the  whole  bone,  such  will  be  its  general  condition.  If,  how- 
ever, there  reside  in  the  part  the  vital  force  capable  of  resisting  the 
disease,  then  from  the  center  outAvard  will  be  observed  a  change  in 
the  character  of  the  lymph  exuded.  The  farther  we  get  from  the 
center  the  more  bland  and  healthy  is  the  exudate  ;  while  the  com- 
plete filling  up  of  the  cells  exhibits  the  wall  of  protection  present 
in  circumscril)ed  healthy  inflammation  of  the  soft  parts.  It  is  to  be 
observed,  however,  that  this  protecting  wall  is  most  apt  to  give 
way  before  the  advance  of  the  disease, — seeming  to  retard,  but  not 
to  check  it.  In  other  words,  nature  seems  seldom  able  to  complete 
a  line  of  demarkation,  as  witnessed  in  necrosis. 

Treatment. — To  do  all  that  can  be  done  in  these  cases  is  not 
at  all  difficult.  If  inflammation  of  the  bone  exists  in  an  acute  stage 
it  is  to  be  treated  on  general  principles :  cathartics,  diaphoretics, 
counter-irritants,  hot  pediluvia,  leeches,  the  general  abstraction  of 
blood,  any  or  all  these  means  being  bi'ought  into  requisition,  the 
practitioner  being  influenced  alone  by  the  resistance  of  his  case. 
If  a  periosteally  inflamed  tooth  be  the  cause  of  the  inflammation, 
as  is  most  frequently  the  case,  such  tooth  is  to  be  removed  or  treated; 
generally,  however,  I  think  it  will  be  found  sufficient  to  scarify  the 
gums,  give  a  hot  foot-bath,  apply  a  blister  to  the  back  of  the  neck, 


C ABIES   OF   THE  MAXILLA.  307 

and  administer  a  saline  cathartic.  If  such  a  course  should  not 
abort,  or  conquer  the  trouble,  then  thi-ee  or  four  Swedish  leeches 
may  be  applied  directly  to  the  Inflamed  part,  this  being  easily  ac- 
complished by  introducing  a  napkin  back  of  the  middle  of  the  roof 
of  the  mouth.  If  even  this  should  not  succeed,  and  the  patient  is 
plethoric,  blood  may  be  taken  from  the  arm.  It  is,  however,  fre- 
quently the  case  that  even  what  may  be  viewed  as  the  acute  stage 
will  be  found  of  an  asthenic  type.  In  these  cases,  conjoined  with 
the  local  depletion,  tonics  will  be  demanded :  iron,  quinia,  beef 
essence,  cod-liver  oil  being  indicated.  If,  when  a  case  is  first  seen, 
the  caries  may  have  become  established,  as  recognized  by  the  ex- 
istence of  fistulse,  the  honeycomb  bone,  etc.,  vigorous  tonic  medica- 
tion, conjoined  with  stimulating  injections,  may  be  tried.  Of  such 
injections,  the  tinct.  of  iodine,  carbolic  acid,  tinct.  capsicum  comp., 
and  chloride  of  zinc,  will  be  found  as  promising  as  any.  Of  the 
tonics,  I  presume  a  common  experience  will  give  to  the  chalybeates 
the  preference.  It  is  not,  however,  from  the  medication  alone  that 
a  cure  is  commonly  to  be  expected.  In  caries  nature  seems  unable 
to  throw  off  the  incubus  of  the  disease ;  and  the  cases  are  rare  in- 
deed where  a  relief,  by  operative  means,  will  not  be  found  impera- 
tively demanded. 

To  operate  for  caries  of  the  jaws  one  seldom  requires  more  than 
two  or  three  curved  chisels,  a  scalpel,  syringe,  and  alum-water. 
Taking  the  fistulae  for  the  guide,  the  bone  is  exposed  by  a  simple 
incision.  Next,  with  a  chisel,  suitable  in  size,  the  softened  bone  is, 
little  by  little,  cut  away. 

The  extent  to  which  caries  will  occasionally  be  found  to  have 
progressed  will  be  a  matter  of  surprise.  One  can  do  no  better,  how- 
ever, than  follow  the  softened  bone,  wherever  it  may  lead.  I  have 
very  frequently,  in  this  way,  been  led  from  an  apparent  simple  be- 
ginning, to  remove  nearly  or  quite  all  of  the  upper  jaw.  Danger 
from  hemorrhage  has  not  been,  in  my  experience,  any  special  occasion 
of  anxiety;  indeed,  I  fail  to  recall  a  case  in  which  the  injection  of  the 
alum-water  has  not  been  all-sufficient  for  its  control.  When  healthy 
bone  is  reached  in  an  operation,  it  is  distinguished  from  the  carious 
both  by  the  touch  and  sight.  Under  the  chisel  the  first  is  hard  and 
springy,  the  latter  soft  and  brittle ;  passing,  with  the  chisel,  from 
the  diseased  to  healthy  tissue,  one  could  not  fail  to  remark  a 
difi"erence.  To  the  sight,  healthy  bone  is  white  and  vascular;  carious 
bone  is  dark  and  non-vascular,  or  it  is  a  deadish  white,  or  oleagi- 
nous.    A  very  observable  difference  between  caries  and  necrosis 


308  ORAL  DISEASES  AND  SURGERY. 

consists  in  the  absence,  in  the  former,  of  the  odor  associated  with 
the  latter,  caries  running  its  whole  course  without  necessarily  giving 
the  slightest  annoyance  from  this  cause;  at  least,  where  proper 
cleanliness  has  been  observed. 

The  use  of  the  syringe,  after  an  operation  for  caries,  is  of  the 
greatest  moment ;  the  capacity  should  not  be  of  less  than  one  gill, 
and  every  particle  of  debris  is  to  be  carefully  washed  away.  In  the 
after-treatment,  this  instrument  will  also  be  found  to  perform  good 
service — repeated  washings  being  very  conducive  to  the  cure. 


CHAPTER    XXI. 


NECROSIS. 


Necrosis,  while  common  to  both  superior  and  inferior  maxillae, 
exhibits  the  most  decided  preference  for  the  latter,  attacking  it  per- 
haps in  twenty  cases  to  five  of  the  former.  The  disease  may  com- 
mence as  an  ostitis  overwhelming  the  bone  in  mass,  and  destroying 
it.  Or,  as  commonly  witnessed,  it  is  produced  by  a  periosteal  in- 
flammation, this  membrane  being  separated  from  the  bone  by  a  de- 
generating plastic  exudate.  In  such  inflammations  and  separations,  it 
would  be  inferred  the  layer  of  bone  immediately  adjacent  to  the  mem- 
brane would  be  the  first  to  be  affected;  this  is  so  truly  the  case 
that  timely  incisions  and  timely  combating  of  the  inflammation  are 
most  influential  in  the  limitation  of  the  disease.  The  superior  jaw, 
however,  is  much  more  liable  to  take  on  a  general  inflammation  than 
the  inferior  ;  but  this  higher  vascularity  and  susceptibility  enables  it 
to  resist  the  destructive  action  and  limit  the  part  overwhelmed. 

Inflammation  of  the  jaws,  whether  osteal  or  periosteal,  are  prima- 
rily to  be  treated  on  general  principles.  If  acute  in  character  we  may 
first  try  the  effect  of  the  hot  pediluvia  and  saline  cathartics.  These 
failing,  the  parts  may  be  well  scarified,  or  leeches  may  be  applied ; 
or  blood  taken  from  the  arm.  Diaphoresis  may  be  employed.  In 
short,  antiphlogistics  of  any  and  every  nature,  promising  control 
of  the  excitement,  may  be  pressed  into  service.  If  all,  however, 
should  fail,  and  pus  be  formed,  it  cannot  too  soon  have  vent  given  it. 
When,  on  the  contrary,  the  inflammation  is  chronic  and  asthenic 
in  character,  with  the  necessity  for  free  scarification  will  exist  a 
demand  for  local  stimulating  douches  and  the  administration  of 
tonics.  Of  the  supporting  medicines  applicable  to  these  cases,  the 
very  best  I  think  will  be  found  in  the  union  of  sulphate  of  quinia 
with  the  muriated  tincture  of  iron.  A  combination  very  frequently 
employed  is  as  follows  : 

R. — Tinct.  ferri  chl.  ^i ; 
Quinia  sulph.  5'-      M. 
Sig.  15  drops  in  water  four  times  a  day  for  adult. 

(309) 


310  ORAL  DISEASES  AND   SURGERY. 

The  most  intractable  cases  of  ostitis  occur  in  the  periods  connected 
with  dontition,  whether  first  or  second,  the  irritability  being  in- 
creased aad  kept  up  by  the  excitability  associated  with  this  process. 
Hence  the  great  amount  of  care  necessary  to  guard  against  any  in- 
crease in  the  natural  vascularity  of  such  age.  The  trouble  aroused, 
nothing  can  be  done,  however,  beyond  such  treatment  as  applies  to 
ordinary  cases;  except,  indeed,  it  will  be  found  that  there  exist  a 
greater  necessity  for  the  use  of  sedative  medicaments.  Ostitis,  or 
periostitis,  of  a  maxillary  bone,  like  as  occurring  in  other  bones,  can 
mostly  be  traced  to  an  influencing  cause  ;  whatever  may  be  this 
cause,  local  or  constitutional,  the  primary  indication  is  its  removal 
where  possible. 

Dental  Necrosis. — Dental  necrosis,  death  of  the  teeth,  or  death 
of  the  neighboring  bone  from  causes  associated  with  the  teeth,  may 
claim  attention  as  being  the  most  common  of  all  the  troubles  of  the 
ossa  corpore. 

A  tooth  has  a  twofold  source  of  vitality — an  internal  or  tubular 
circulation,  secured  from  its  pulp,  and  an  external  or  periosteal. 
The  destruction  of  this  internal  circulation,  through  the  killing  of 
the  nerve  and  filling  the  root-canal  by  the  dentist,  is  so  common  an 
occurrence  as  to  be  familiar  to  almost  every  one. 

By  the  majority  of  teeth,  if  properly  treated,  this  destruction 
seems  to  be  sustained  without  much  apparent  inconvenience.  Such 
treatment  consists  in  extracting  from  the  cavity  every  particle  of 
the  dead  pulp,  and  so  filling  it  with  gold  or  other  material  as  to 
prevent  the  introduction  of  more  irritating  matter.  When  teeth, 
however,  are  not  properly  treated,  or  when  there  is  great  suscepti- 
bility in  the  system  to  inflammatory  action,  the  destruction  of  the 
pulp  results  in  an  extension  of  the  destructive  action  to  the  peri- 
dental membrane,  yielding  the  trouble  known  as  periodontitis  ;  this, 
if  not  aborted  or  resolved,  ends  in  the  death  of  the  tooth. 

A  dead  tooth  is  not,  however,  fortunately,  treated  in  all  cases  by 
the  system,  or  even  in  the  majority  of  cases,  in  so  summary  a  man- 
ner as  a  piece  of  dead  bone.  As  a  rule,  there  exists  a  wonderful 
forbearance  on  the  part  of  nature  to  its  presence,  and  the  organ  may 
be  retained  in  its  cavity  and  made  to  serve  a  useful  purpose  for  a 
long  time.  True,  it  is  discolored,  and,  providing  there  is  no  decom- 
posing pulp  in  the  canal,  in  proportion  to  this  discoloration  may  the 
degree  of  death— if  I  may  so  speak— be  judged.  A  tooth  lowers  in 
the  scale  of  vitality  in  various  degrees.  It  may  be  deteriorated  as 
the  death  of  part  of  its  pulp  is  concerned,  or  as  the  death  of  all  of  it 


NECROSIS.  311 

is  implied — as  regards  the  whole  or  any  part  of  its  periosteum. 
When  both  pulp  and  periosteum  are  dead,  the  tooth,  of  necessity, 
must  be  dead  with  them,  and  in  proportion  to  their  destruction,  so 
is  its  destruction. 

Some  systems  are  so  irritable  that  all  the  skill  in  the  world  could 
not  make  the  mouths  retain  a  tooth  in  which  alone  the  pulp  is  dead. 
Others,  on  the  contrary,  are  so  unimpressible  that  half  the  teeth  in 
the  mouth  might  be  utterly  dead,  and  yet  no  complaint  be  made.  I 
once,  as  an  experiment,  replaced  in  the  mouth  a  central  incisor  tooth, 
which  had  been  extracted  twelve  hours  before,  and  although  it  had 
been  carried  in  the  pocket,  enveloped  in  the  usual  collection  of  dust, 
tobacco,  keys,  knife,  etc.  the  whole  intervening  time,  I  kept  it  in  its 
socket  until  the  parts  became  reconciled.  Many  years  have  since 
passed,  and  it  seemed  to  me,  when  last  I  saw  it,  about  as  useful  as 
in  its  palmiest  days. 

The  irritation,  inflammation,  and  death  of  a  tooth  are  generally  the 
result  of  caries  exposing  its  pulp.  The  first  stage  in  the  destruc- 
tive process  is  the  death  of  this  part* — here  it  may  end,  the  pulp 
sloughing  off"  at  the  foramen,  and  the  periosteum  assuming  the  full 
duties  of  nutrition.  If  this  is  not  the  case,  the  periosteum  becomes 
involved ;  if  it  too  should  die,  the  root  is  left  as  if  scraped  ;  the  tooth 
is  then  dead.  A  dead  or  partly  dead  tooth  is  recognized  by  its  loss 
of  translucency,  opacity  varying  from  the  slightest  discoloration  to 
complete  blackness. 

A  dead  tooth  is  not,  however,  necessarily  associated  with  caries. 
Inflammation  resulting  in  its  destruction,  may  be  induced  by  at- 
mospheric changes,  blows,  etc.  This  should  be  recognized,  so 
that  by  reason  of  the  absence  of  caries  a  diagnosis  may  not  be 
obscured. 

A  dead  tooth,  when  exfoliated,  is  thrown  oif  in  two  ways:  either 
by  chronic  or  acute  action.  When  by  acute  means,  violent  inflam- 
mation is  set  up  in  all  the  surrounding  parts,  the  tooth  is  elongated 
and  loosened,  much  pus  is  discharged,  and  eventually  the  tooth 
drops  from  its  socket ;  this  accomplished,  the  trouble  subsides.  In 
chronic  exfoliation,  the  parts  indurate,  one  or  more  sinuses  form  as 
in  abscess,  all  the  parts  about  the  tooth  are  thickened  and  rough,  as 
if  some  ugly  disease  was  in  process  of  development,  the  tooth  gen- 
erally grows  dark,  perhaps  black.  It  does  not  get  loose,  but  frightens 


*  The  pnlp  of  a  tooth  is  composed  of  most  delicate  connective  tissue,  in 
which  ramify  the  vessels  and  nerve. 


312  ORAL  DISEASES  AND   SURGERY. 

into  its  removal.  If  such  extraction  be  not  resorted  to,  the  disease 
involves  the  bone,  and  tooth  and  alveolus  become  eventually  cast 
ofiF  as  a  common  sequestrum.  Another,  and  more  common  chronic 
form,  consists  in  the  gradual  absorption  from  about  the  roots  of  the 
dead  tooth  of  its  alveolar  process.  This  is  most  common  to  old 
persons,  although  not  by  any  means  so  confined.  This  form  of  ex- 
foliation is  usually  very  slow  in  its  progress,  extending  over  a  period 
sometimes  of  several  years.  Cases,  however,  frequently  present — 
confined  to  young  persons — where  several  teeth  are  cast  off  in  this 
manner  within  eight  or  nine  months. 

Teeth  sometimes  die  from  the  filling  up  of  their  tubules  by 
secondary  dentine,  the  organic  function  residing  in  the  tubes  being 
thus  destroyed.  This  never  occurs  but  in  what  are  commonly  re- 
cognized as  very  dense  teeth,  and  is  seldom  found  associated  with 
caries.  Such  teeth  loosen  day  by  day,  and  finally  drop  from  their 
cavities.  To  arrest  this  trouble  seems  impossible.  I  know  of  no 
treatment  that  has  ever  seemed  to  have  the  least  effect. 

Alveolar  Necrosis. — The  periosteum  enveloping  the  root  of  a 
tooth  is  reflected  to  its  alveolus,  hence  it  is  commonly  termed  the 
"  alveolo-dental  periosteum."  As  the  result  of  such  relationship  of 
structure,  an  inflammation  originating  in  a  tooth  extends  itself  to 
the  surrounding  bone,  and  according  to  its  severity,  affects  the  parts 
involved  ;  hence  portions  of  alveolus,  overwhelmed,  as  it  were,  by 
the  force  of  the  attack,  sometimes  die  and  sequester.  This  form  of 
necrosis,  however,  is  not  very  common,  and  would  perhaps  with 
proper  treatment  seldom  occur. 

The  dentist,  for  the  purpose  of  destroying  the  pulps  of  teeth, 
applies  a  mixture  of  arsenic,  morphia,  and  creasote.  This  is  placed 
in  the  cavity  of  decay  and  covered  with  cotton  or  wax;  it  hap- 
pens, however,  occasionally,  that  from  its  improper  application,  or 
some  difficulty  of  retaining  it  in  place,  this  paste  oozes  down  around 
the  neck  of  the  tooth,  and  thus  acts  upon  parts  not  intended  in  its 
application,  inflaming  them  ;  in  this  way  alveolar  necrosis  is  some- 
times induced :  the  portion  destroyed  is  seldom,  however,  very  con- 
siderable, and  generally  exfoliates  in  from  two  to  four  weeks.  The 
local  application  of  the  sesquioxide  of  iron  has  been  thought  by 
some  to  exert  a  happy  effect,  applied  immediately  on  the  discovery 
of  the  accident.     Repeated  syringings  are  not  to  be  neglected. 

Alveolar  necrosis  is  sometimes  induced  by  the  application  of 
chloride  of  zinc,  used  by  the  dentist  as  an  obtunder  of  dentinal  sen- 
sibility, and  also  for  the  purpose  of  controlling  the  slight  hemorrhages 


NECROSIS.  313 

caused  by  the  slipping  of  instruments  in  the  operation  of  filling ;  the 
first  effect  is  of  course  upon  the  gum,  inflaming  and  engorging  it, 
the  effect  upon  the  bone  being  secondary.  Nothing  better  than  the 
ordinary  antiphlogistic  applications  can  be  employed.  The  action 
here  is  much  more  tardy  than  in  the  destruction  induced  by  arsenic, 
the  sequestrum  is  never  very  considerable,  the  alveolus  perhaps  of  a 
single  tooth.  The  action  of  nature,  in  the  separation,  should  always 
be  awaited.  Cases  of  what,  for  want  of  a  better  name,  might  be 
termed  anomalous,  sometimes  occur.  An  instance  will  illustrate. 
I.  B.,  an  Irish  laborer,  consulted  for  pain  in  the  two  inferior  in- 
cisor teeth, — no  caries,  no  periosteal  inflammation,  nothing  indicating 
disease,  was  observable ;  the  pain  increased  day  by  day,  until  at  the 
end  of  the  second  week  the  two  teeth  and  their  alveoli  were  found 
detached,  and  were  dissected  from  the  gum.  This  case  is  one  of  a 
very  few  of  the  kind  that  I  have  seen.  The  nerves  are  not 
found  dead  if  examined  at  such  time,  as  under  ordinary  circum- 
stances one  would  so  expect  to  find  them  ;  there  is  no  soreness  of 
the  teeth  on  pressure,  and,  strangest  of  all,  there  ai-e  none  of 
the  common  phenomena  of  inflammation.  The  practitioner  in  these 
cases  must  be  guided  by  such  indications  as  he  may  be  able  to  seize 
upon. 

Necrosis  from  Want  of  Room  for  Eruption  of  Wisdom  Tooth. — 
This  most  commonly  is  found  associated  with  the  lower  jaw.  The 
close  relationship  of  the  second  molar  with  the  ramus,  makes  the 
egress  of  the  advancing  wisdom  tooth  an  impossibility;  hence  an 
irritation  resulting  in  inflammation.  The  serious  extension  of  the 
trouble  to  the  bone  is  always,  however,  preceded  by  more  or  less 
trismus  and  difficulty  in  deglutition  ;  thus  every  chance  is  given  for 
surgical  relief.  This  form  of  necrosis  is  to  be  looked  for  between 
the  seventeenth  and  twenty-fifth  years.  The  extraction  of  the  second 
molar  allows  the  wisdom  tooth  to  fall  forward ;  thus  the  irritation 
is  removed  and  a  cure  effected.  These  cases  are,  if  rightly  treated, 
as  simple  and  harmless,  as  they  are  severe  and  prostrating  if  left 
to  chance  or  improperly  managed.  Extract  the  second  molar  tooth, 
and  do  not  attempt  the  removal  of  the  offending  one — that  is,  if  such 
extraction  will  be  found  difficult. 

Exfoliations  of  laminae  of  bone  are  very  common  after  the  opera- 
tion of  extraction. 

Such  scales  vary  in  size  from  that  of  the  finger-nail  to  a  pin's  head ; 
they  seldom  require  any  particular  attention. 

Phosphor-Necrosis. — Outside  of  the  association  of  a  patient  with 


314  ORAL   DISEASES  AND  SURGERY. 

phosphorus,  there  is  nothing  which,  to  an  ordinary  observer,  would 
distinguish  the  incipient  condition  of  this  loathsome  disease  from  a 
case  of  commonly  severe  periodontitis. 

The  first  sign  of  a  commencing  phosphor-necrosis  is  found  in  one 
or  more  teeth  becoming  sore  to  the  touch,  feeling,  on  occlusion,  as  if 
raised  in  their  sockets;  a  short  time,  and  the  surrounding  gum 
begins  to  swell :  in  the  character  of  this  swelling  is  the  first  dis- 
tinctive sign.  It  is  not  the  acute,  firm,  inflammatory  swelling  of 
periodontitis,  or  ordinary  necrosis,  but  from  the  beginning  has  a 
puffy,  debased,  and  degenerating  look.  You  feel  as  if  you  might 
hesitate  in  adopting  any  very  decided  antiphlogistic  treatment,  or, 
indeed,  in  employing  any  other  than  an  expectant  one. 

Phosphorus  acts  both  on  the  upper  and  lower  jaw-bones,  but, 
according  to  my  observation,  seems  to  have  a  much  more  decided 
predilection  for  the  lower ;  as  nine  to  twelve,  perhaps. 

The  history  of  a  case  of  phosphor-necrosis  might  be  epitomized 
as  follows :  either  from  a  local  or  constitutional  influence,  the  latter, 
most  likely,  a  degenerative  inflammation  commences  in  the  alveolo- 
dental  periosteum,  or  in  the  substance  of  the  bone ;  I  incline  most 
strongly  to  the  belief  of  its  commencement  in  the  latter.  The  de- 
generation of  this  bone  progresses  until  its  enveloping  periosteum — 
which  remains  unaffected,  as  its  vitality  is  concerned — separates 
from  it.  The  bones  die  in  bulk  or  in  part.  In  the  lower  jaw, 
the  body  alone  commonly  dies,  the  rami  remaining  unaffected. 
In  the  upper,  one  cannot  well  infer  where  the  demarkatiou  will 
occur.  During  this  process  of  death,  the  periosteum,  particularly  in 
the  lower  jaw,  is  most  active  in  the  reproduction  of  new  bone,  this 
new  bone  enveloping  the  dead,  not,  according  to  my  observation, 
completely,  but  below  and  on  the  sides,  making  a  gutter,  as  it  were, 
holding  the  dead  bone.  The  separation  of  the  dead  from  the  living 
bone,  when  the  dead  part  is  at  all  extensive,  occupies  a  period  of 
from  seven  to  nine  months,  and  is  attended  with  the  formation  of 
many  sinuses,  both  in  the  mouth  and  about  the  neck,  being  very 
exhaustive  to  the  patient,  both  on  account  of  the  great  suppurative 
drain  and  the  nauseating  character  of  the  discharge.  The  whole  of 
the  soft  parts  associated  with  the  affected  jaw,  the  periosteum  per- 
haps excepted,  sympathize  warmly  during  the  process  of  the  dying 
and  separation,  looking,  indeed,  as  if  very  badly  affected  with  scurvy. 
At  the  period  above  alluded  to,  the  separation  being  completed, 
the  surgeon  may  remove,  with  little  effort,  the  sequestrum;  the 
sinuses  then  heal,  and  the  parts  recover  with  as  little  deformity  as 


NECROSIS.  315 

attends  the  extraction  of  the  teeth  and  the  ordinary  absorption  of 
the  alveolar  process. 

This,  I  think,  will  be  found  the  common  history  of  the  disease. 
I  have  seen  and  treated  many  cases,  and  it  is  thus  that  it  has  pre- 
sented itself  to  my  observation.  I  might  perhaps  add,  that  the 
teeth,  influenced  by  the  advancing  disease,  loosen  one  by  one,  so  as 
to  make  necessary  their  removal  long  before  the  bone  is  ready  to 
come  away. 

The  treatment  pursued  in  phosphor-necrosis  consists  in  the  em- 
ployment of  means  which  shall  circumscribe  as  much  as  possible  the 
disease,  which  shall  hasten  the  process  of  limited  death  and  the  ac- 
cruing separation,  and  which  shall  support  the  patient  under  the 
drain  to  which  he  is  necessarily  subjected. 

Acting  on  the  impression  that  there  may  exist,  either  in  a  systemic 
or  local  relation,  phosphorus,  whose  force  may  be  susceptible  of  neu- 
tralization, we  direct  both  locally  and  internally  the  mineral  antacids, 
— the  ordinary  magnes.  carb.  is  perhaps  as  good  as  any  other;  a  tea- 
spoonful  twice  each  day  in  a  goblet  of  water.  In  the  mouth,  as 
much  as  may  be  laid  on  a  three-cent  piece  may  be  used  three  or 
four  times  a  day;  this  local  and  systemic  medication  is,  by  the  way, 
a  very  admirable  prophylactic  to  unaffected  workmen. 

When  a  case  presents  in  its  very  incipiency,  that  is,  simulating  a 
developing  periodontitis,  we  commence  the  local  treatment  just  as  we 
would  that  of  the  periodontitis.  If  the  inflammation  has  about  it 
anything  of  a  healthy  acuteness,  we  limit  as  much  as  possible  all  ex- 
ternal irritation,  by  softening  in  the  gas  flame  or  by  the  stove  a  piece 
of  gutta-percha,  and  moulding  it  over  some  opposite  tooth,  or  tooth 
farthest  removed  from  the  seat  of  trouble  ;  a  mouthful  of  cold  water 
hardens  this  cap,  and  thus  occlusion  against  the  sore  tooth  or  teeth 
is  prevented.  A  dose  of  Epsom  salts  or  other  saline  cathartic  is 
ordered,  and  a  mustard  poultice  is  applied  to  the-  side  of  the  face  or 
back  of  the  neck.  A  hot  pediluvium  is  found  sometimes  to  act  very 
happily  as  a  derivative ;  or  a  diaphoretic,  such  as  the  spirits  of  Min- 
dererus,  may  serve  a  very  good  end. 

If  we  first  see  the  case — and  this  is  most  apt  to  occur — when  a 
discharge  has  made  passage  for  itself  by  opening  through  the  gum 
at  the  neck  of  a  certain  tooth  or  teeth,  we  immediately  make  a  free 
incision  through  the  soft  parts  down  upon  the  bone,  and  syringe  the 
parts  thoroughly  with  some  medicated  water,  stimulating  or  antisep- 
tic, or  both,  as  indicated.  Having  the  parts  well  cleansed,  we  stuff 
the  wound  which  has  been  made  with  cotton  or  sponge.     This  is 


316  ORAL  DISEASES  AND  SURGERY. 

repeated  the  next  day  and  the  next,  until,  particularly  as  the  syring- 
inff  is  concerned,  it  maybe  absolutely  necessary  to  repeat  it  a  dozen 
or  twenty  times  per  diem,  the  progress  of  the  disease  being  so 
marked  by  discharge  and  offcnsiveness.  As  day  by  day  the  cotton 
or  sponge  stuffing  is  renewed,  it  is  insinuated  gently  between  the 
separating  periosteum  and  bone.  This  manipulation  will  be  found 
to  hasten  the  separation  wonderfully,  and  expedite  the  cure  of  the 

case. 

It  might  here  be  asked,  perhaps,  by  some  one,  "  Is  not  this  pro- 
cess of  working  off  the  periosteum  an  unsurgical  proceeding,  com- 
pelling an  extension  of  the  disease  beyond  that  which  would  have 
been  the  result  if  left  to  itself?"  I  can  only  answer  from  my  own 
experience  in  different  modes  of  treatment,  and  say  that  I  am  per- 
fectly satisfied  that  this  is  not  the  case,  and  that  the  result  is  for  the 
good  of  the  patient  in  every  way :  the  portion  of  bone  destined  to 
die  has  its  death  markedly  hastened  ;  the  sooner  the  death  the 
sooner  the  separation ;  the  sooner  the  separation  and  exfoliation  of 
the  sequestrum,  the  less  exhaustive  to  the  system. 

The  compound  tincture  of  capsicum,  with  an  excess  of  myrrh  and 
an  addition  of  the  permanganate  of  potash,  is  an  excellent  wash  for 
the  mouth  in  these  cases.  Cold  water,  with  a  little  common  salt 
dissolved  in  it,  can  be  used  ad  libitum. 

The  sinuses  which  are  so  apt  to  form  upon  the  neck,  in  defiance  of 
all  treatment,  and  which  greatly  annoy  by  their  discharge,  are  most 
comfortably  treated  with  dressings  of  patent  lint.  Once  formed,  it 
is  a  waste  of  time  to  attempt  the  healing  of  them ;  they  will  only 
get  well  when  the  source  of  offense  in  the  dead  bone  is  removed. 
I  never  have  been  able  to  heal  one  before. 

It  has  been  remarked  that  the  death  is  limited  in  the  lower  jaw 
to  the  body  of  the  bone,  the  horizontal  portion,  the  demarkation 
occurring  at  the  angle.  This,  in  the  majority  of  instances,  will  be 
the  case,  particularly  if  the  treatment  has  been  properly  directed. 
Seven  months  will  be  found  the  minimum  required  for  the  course 
of  the  disease ;  nine  months  the  more  common  time ;  and  fifteen 
the  maximum.  The  drain  during  most  of  this  time  is  immense,  the 
patient  requiring  the  most  generous  tonics  and  substantial  fare. 
Attention  to  the  repair  of  this  wear  and  tear  is,  perhaps,  of  greater 
consequence  than  any  local  treatment ;  certainly,  if  I  could  not 
have  both,  I  would  think  my  chances  best  with  the  former.  To 
commence,  however,  with  the  ordinary  medicinal  tonics,  is  ill  ad- 
vised.    One   cannot  keep  on   forever  with   them,  and  by  an  em- 


NECROSIS.  317 

ployment  of  them  in  the  beginning  of  the  disease,  we  lose  their  pow- 
erful assistance  at  a  time  when  every  help  is  found  weak  enough  at 
the  best.  Good  underdone  roast  beef  is  quite  enough  for  the  first  two 
or  three  months,  then  an  addition  may  be  made  of  generous  malt 
liquors,  together  with  the  salt-bath.  The  latter  portion  of  the  time 
will  demand  iron,  quinine,  brandy.  The  hemorrhages,  sometimes  so 
profuse,  are  held  very  well  in  check  by  the  exhibition,  once  or  twice 
weekly,  of  tinct.  Erigeron  Canadeuse. 

The  period  at  which  a  sequestrum  is  ready  to  be  taken  away  can 
only  be  known  by  repeated  examination,  the  proper  treatment  be- 
ing to  wait  always  until  the  separation  is  complete,  be  such 
time  longer  or  shorter.  Nothing,  I  am  satisfied,  is  gained  by  ex- 
pediting the  removal  through  operative  proceedings,  as  by  break- 
ing away  the  bone,  using  the  chain-saw,  etc.,  while  the  risk  to 
life  is  very  considerable.  To  wait  patiently,  keeping  the  system  ca- 
pable to  the  demand  on  it,  is  the  surgeon's  highest  duty ;  to  do  more 
is  to  do  harm. 

The  removal  of  the  bone  is  always  to  be  effected  from  the  inside. 
I  do  not  think  an  outside  incision  will  ever  be  found  necessary.  If 
the  opening  along  the  gum,  obtained  in  the  treatment,  is  not  great 
enough,  it  is  easily  enlarged  to  an  extent  desired. 

A  step  preliminary  to  the  removal  of  the  body  of  the  lower  jaw, 
is  its  division  at  the  symphysis.  This  is  most  easily  accomplished 
by  means  of  the  straight-cutting  forceps.  It  is  better  to  cut  little 
by  little,  from  above  downward,  than  to  crush  through  the  bone 
with  a  single  cut ;  it  does  not  hurt  or  shock  nearly  so  much.  The 
operation  is  not  a  severe  one,  seldom  demanding  the  patient  to  be 
etherized,  yet  it  is  generally  enough  to  be  borne  at  one  sitting. 

To  take  away  the  bone,  I  have  never  found  anything  better  than 
the  ordinary  tooth  forceps,  such  as  is  in  common  use  for  the  extrac- 
tion of  the  inferior  incisors  and  bicuspids.  With  such  forceps, 
perfect  control  of  the  part  is  secured,  and  the  removal,  as  a  general 
rule,  easily  effected. 

A  trouble  frequently  encountered,  and  one  which,  undistinguished, 
would  prove  confusing  and  deceptive,  consists  in  a  grasping  of  the 
sequestrum,  when  extensive,  by  the  lateral  overlying  tissues — not 
the  new  bone,  but  the  indurated  soft  parts.  I  recall  just  now  a  case 
which  I  once  had  under  treatment,  where  the  dead  bone  being  thus 
held,  the  physician  had  been  waiting  for  the  separation  a  period  of 
over  two  years,  being  deceived  entirely  as  to  the  condition  of  the 
part.    To  satisfy  one's  self  as  to  the  state  of  parts,  pass  a  small  hook 


318  ORAL  DISEASES  AND   SURGERY. 

under  the  bone,  and  lift :  if  the  bone  yields  springy,  it  is  only  thus 
held,  and  may  with  safety  be  pulled  through;  if,  on  the  contrary, 
it  is  firm  and  unyielding,  it  is  to  be  left  alone,  separation  has  not 
yet  taken  place. 

In  the  reproduction  of  the  new  bone,  which,  at  the  period  for  the 
removal  of  the  old,  will  be  found  to  have  obtained  such  character  as 
to  keep  up  perfectly  the  shape  of  the  parts,  the  observer  will  be 
struck  with  the  excess  deposited  along  the  middle  line  of  the  mouth ; 
it  seems  as  if  the  floor  was  a  mass  of  bone,  and  which,  indeed,  it 
really  is.  Nothing,  however,  will  be  found  necessary  to  be  done 
with  this  excess,  nature  taking  all  proper  care  of  it. 

Phosphor-necrosis  attacking  the  upper  jaw  is  not,  I  think,  so 
much  to  be  dreaded  as  that  associated  with  the  lower.  It  is  seldom 
so  formidable  in  its  nature  or  so  destructive  in  its  progress.  I  have 
seen  the  disease  in  these  parts  run  its  whole  course  with  an  entire 
absence  of  acute  action.  A  portion  of  bone  dies,  and  the  surrounding 
soft  parts  seem  utterly  indifferent.  One  would  scarcely  know  any- 
thing abnormal  was  going  on  were  it  not  for  the  indication  given 
in  the  loosening  of  the  teeth;  these  drop  out  somewhat  as  they 
would  out  of  the  dried  skull.  This,  however,  is,  of  course,  not  the 
common  history.  The  inflammatory  action  is  of  the  same  type  as 
that  associated  with  the  disease  in  the  lower  jaw,  but  more  limited 
in  extent  and  consequence,  and  much  more  susceptible  to  remedial 
measures.  A  bad  feature  consists  in  a  marked  tendency  to  recur- 
rence of  the  trouble,  but  I  believe  this  will  mostly  be  found  to  be 
within  the  control  of  the  surgeon.  I  think  I  am  justified  in  saying 
I  have  commonly  found  it  so.  The  removal  of  a  sequestrum  here 
is  a  trifling  matter,  comparatively  little  dissection  letting  the  piece 
pass. 

At  the  Medical  Congress  in  Zurich,  Switzerland,  Professor  Bill- 
roth, in  citing  his  experience  with  phosphor-necrosis,  remarked  that 
in  attacking  the  upper  jaw  it  seemed  to  act  with  greater  and  more 
destructive  force,  and  was  more  unmanageable. 

I  do  not  know  how  to  reconcile  these  differences  in  clinical  ob- 
servation, unless  an  explanation  maybe  found  in  the  implied  greater 
tendency  to  return  which  exists  on  the  part  of  the  disease,  when 
situated  in  the  upper  jaw.  In  the  lower  jaw  the  full  part  that  is  to 
die  seems  impressed  from  the  beginning, — that  is  to  say,  a  certain 
portion  seems  predestined  to  die,  and  it  dies  in  defiance  of  all  you 
may  do.  Not  that  the  evidence  of  the  disease  is  general  over  all 
the  involved  part  from  the  beginning  ;  on  the  contrary,  the  incipient 


NECROSIS.  319 

stage  is  markedly  localized ;  but  then,  day  by  day,  and  week  by 
week,  the  trouble  extends  over  the  apparently  predetermined,  or  pre- 
impressed,  part.  When  the  death  occurs,  it  is  a  single  death,  and 
when  the  piece  is  cast  off,  there  is  not  apt  to  be  any  renewal  of  the 
trouble.  The  sequestrum  of  the  upper  jaw,  on  the  contrary,  is 
generally  small,  some  portion,  most  likely,  of  the  alveolar  process, 
but  unless  the  treatment  is  of  the  most  supporting  and  specific  kind, 
it  is  apt  to  repeat  itself,  again  and  again  ;  but  your  treatment  will 
be  responded  to  here,  and  thus,  with  care  and  attention,  you  have 
the  amount  of  destruction  comparatively  under  control.  If  it  is 
found  more  unmanageable  in  Zurich,  then  the  means  would  not 
seem  to  be  so  well  adapted  to  the  end  as  those  here  employed,  or 
otherwise  the  circumstances  must  be  different. 

Again,  at  the  same  Congress  frequent  resections  are  commended. 
To  be  so  commended,  they  must,  of  course,  have  been  found  to 
answer  a  good  purpose.  The  patients  Avho  have  their  jaws  resected 
for  phosphor-necrosis  disease  in  this  country  generally  die,  or  if 
happily  they  escape  death,  they  do  not  find  their  disease  cured 
without  an  inflammatory  sequestrum  at  last. 

Fig.  64. — Appearance  of  Patient  with  Phosphor-Necrosis. 


This  case,  taken  from  life,  represents  a  patient  as  he  appeared 
with  the  disease  five  months  in  progress.  At  the  end  of  eight 
months  I  removed  the  jaw  at  the  articulation, — the  loss  was  very 
fully  repaired  at  the  date  of  operation — the  parts  having  excellent 
motion. 

An  important  objection  to  the  operation  of  resection,  even  were 


320  ORAL   DISEASES  AND  SURGERY. 

the  question  of  life  not  involved,  is  the  great  resulting  deformity. 
Let  nature  take  her  course,  and  of  this  there  is  little  or  none.  My 
very  last  patient  was  a  gentleman  for  whom  I  removed — or  rather 
waited  on  nature's  removal — the  whole  body  of  the  inferior  maxilla, 
and  I  will  guarantee  that  no  one  could  tell  whether  it  had  been  a 
case  of  necrosis  or  of  simple  extraction  of  all  the  inferior  teeth,  with 
the  consequent  alveolar  absorption,  so  perfect  has  been  the  repair  in 
accordance  with  the  destruction.  The  objection  that  this  new  bone 
keeps  up  the  trouble  by  becoming  involved  in  the  diseased  action, 
is  not  according  to  my  experience.  If  it  becomes  involved,  1  think 
it  has  not  been  properly  cared  for.  Careful  and  properly  repeated 
syringings  with  water  medicated  with  iodine  and  creasote  will  pro- 
tect it. 

Syphilitic  Xecrosis. — The  hard  palate  seems  particularly  liable 
to  suffer  from  attacks  of  specific  diseases,  the  venereal  ulcer  of  the 
overlying  soft  parts,  and  that  of  the  soft  palate  being  observed  as 
among  the  most  common  of  the  constitutional  affections.  That 
these  ulcers  are,  however,  strictly  venereal,  I  am  oftentimes  led  to 
doubt;  certain  I  am  that  they  appear  and  exist,  with  greatest  viru- 
lence, where  mercury  has  been  used  with  unnecessary  freedom. 
Venereal  ulcers  of  the  mouth  are  of  two  kinds  :  the  superficial  and 
the  ordinary  ulcer  of  necrosis  ;  either  of  them  being  represented  in 
general  appearance  by  the  non-indurated  chancre.  The  superficial 
ulcer  may  be  found  both  upon  the  hard  and  soft  palates,  but  is  much 
more  common  to  the  latter.  These  ulcers — as  the  chancres — vary  in 
size  and  character  :  being  sometimes  very  amenable  to  treatment ;  at 
others,  resisting  and  phagedenic,  even  to  the  destruction  of  the  parts. 
Their  treatment  is  to  be  conducted  on  general  principles.  I  know  of 
few  surgical  conditions  requiring  nicer  general  judgment  or  more 
attentive  care ;  it  is,  really,  to  blow  hot  to-day  and  cold  to-morrow, 
and  vice  versa.  As  a  rule,  such  ulcers  are  oblong  in  form,  from  an 
eighth  to  an  inch  or  more  in  length ;  more  or  less  excavated,  the 
cavity  being  filled  with  a  dirty-white  semi-solid  paste.  The  truest 
comprehension  of  these  cases  is  found,  as  my  experience  leads  me  to 
infer,  in  looking  at  them  as  one  looks  at  scorbutus. 

Touching  locally  with  the  acid  nitrate  of  mercury,  or  with  a  mix- 
ture of  equal  parts  of  iodine  and  creasote,  not  unfrequently  causes 
them  speedily  to  assume  healthy  action.  I  have  never  seen  a  case 
in  which  the  internal  exhibition  of  the  mineral  acids  did  not  seem  to 
be  in  some  degree  useful;  and  particularly  have  I  found  this  to  be 
the  case  where  a  phagedemic  tendency  existed.    Whatever  remedies, 


NECROSIS.  321 

however,  be  employed,  the  venereal  basis  of  the  trouble  is  always  to 
be  kept  in  mind.  Syrup  of  the  pyrophosphate  of  iron,  conjoined  with 
minute  doses  of  corrosive  sublimate  and  iodide  of  potassium,  will, 
under  certain  conditions,  compel  such  ulcers  to  disappear  as  if  by 
magic.     A  combination  which  may  be  employed  is  as  follows : 

B. — Hydrarg.  bichl.  gr.  ij ; 

Potass,  iod.  5ij  5 

Syr.  ferri  pyrophos.  ^iij; 

Syr.  sarsaparilla,  §v.     M. 
Sig.  Tablespoonful  ter  die. 

The  ulcer  of  necrosis,  looking  like  the  preceding,  diflTers  from  it 
in  having  a  sinus  leading  from  the  pasty  mass,  which  constitutes 
the  apparent  bottom  to  dead  or  dying  bone  beneath.  The  ulcer  in 
this  case  is  not  the  trouble  to  be  cured, — indeed,  could  not  be  cured 
while  the  underlying  disease  existed.  Ulcers  of  this  class  being 
an  attendant  condition,  are  always  situated  over  bones,  generally 
about  the  suture  of  the  maxillary  and  palate  bones.  They  are 
always  preceded  by  an  engorged  and  tumid  state  of  the  parts  in 
which  they  are  situated,  indicative  of  the  osseous  trouble  beneath. 
The  character  of  this  tumidity  is  always  a  matter  of  much  concern, 
as  in  proportion  to  its  solidity  will  generally  be  found  the  extent  of 
destruction  in  the  soft  parts ;  the  variability  of  this  destruction  is 
seldom,  however,  in  proportion  to  the  disease  below.  I  have  seen 
the  whole  palatine  process  die  while  the  indicative  ulcer  has  not 
been  larger  than  the  eighth  of  an  inch  in  circumference ;  I  have,  on 
the  contrary,  witnessed  the  smallest  sequestrum  attended  with  the 
largest  ulceration. 

Incisions  into  and  through  this  tumid  engorgement  will  always 
be  found  satisfactory  practice.  The  cuts,  however,  are  to  be  made, 
not  carelessly,  but  with  judgment ;  always  taking  into  consideration 
the  vitality  of  the  part.  These  incisions,  if  made  through  the  peri- 
osteum, will  frequently  be  found  to  exercise  quite  a  controlling  influ- 
ence on  the  ostitis,  just  as  in  cases  of  ordinary  necrosis,  while  the 
effect  upon  the  soft  parts  is  always  for  good.  The  treatment  which 
should  succeed  the  incisions  is  only  to  be  determined  by  the  cir- 
cumstances of  each  particular  case ;  not  unfrequently  it  will  be  found 
amply  sufficient  to  keep  the  parts  well  cleansed,  and  await  the  com- 
ing away  of  the  sequestrum  ;  never,  however,  forgetting  to  meet  the 
constitutional  indication.  In  other  cases,  as  when,  for  example,  the 
phagedenic  type  is  assumed,  the  most  vigorous  and  well-directed 

21 


322  ORAL  DISEASES  AND  SURGERY. 

local  treatment  is  necessitated  ;  when  cases  are  first  seen  in  the  open 
ulcerated  condition,  semi-indolent,  as  is  frequently  the  case,  I  know- 
no  treatment  equal  to  packing  the  ulcer  with  cotton  saturated  with 
creasote  and  iodine.  I  have  had  cases  come  to  me  for  treatment 
where  the  bone  would  be  found  exposed  to  the  size  of  a  silver  three- 
cent  piece,  and  where  all  the  consequences  of  a  large  opening  into 
the  nares  were  to  be  apprehended,  yet,  by  such  an  application  re- 
peated every  other  day,  allowing  the  cotton  to  remain  in  the  ulcer 
the  intervening  time,  in  the  course  of  two  weeks  the  denuded  bone 
has  entirely  granulated  over,  and  the  parts  have  remained  perma- 
nently cured. 

Breaks  occurring  in  the  hard  palate,  associating  the  oral  cavity  with 
the  nares,  are  easily  remedied  by  a  covering  of  gold  or  silver  plate. 
An  impression  of  the  full  roof  of  the  mouth  is  taken  in  wax;  into 
this  plaster  in  a  cream  form  is  poured ;  to  the  cast  thus  procured  is 
fitted  the  plate  of  metal,  supported  by  the  teeth,  or  by  atmospheric 
pressure,  precisely  as  in  the  case  of  a  plate  for  the  attachment  of 
teeth.  Any  reasonably  ingenious  mechanical  dentist  can  meet  the 
indications. 

In  breaks  of  the  soft  palate  a  simple  wad  of  cotton  may  be  tem- 
porarily used  with  a  considerable  degree  of  satisfaction.  Astonishing 
results  in  the  way  of  diminishing  or  closing  these  breaks,  both  in  the 
hard  and  soft  palates,  may  not  unfrequently  be  secured  by  freshening 
the  edges  and  touching  every  second  or  third  day  with  iodine,  zinc, 
acid  nitrate  of  mercury,  or  the  compound  tincture  of  capsicum. 
Great  care  is,  however,  to  be  exercised  in  this  practice  not  to  over- 
stimulate  the  parts,  very  ugly  degenerating  inflammations  being 
sometimes  the  result  of  an  overexcitement. 

An  ugly  feature  in  the  syphilitic  ulcer  is  its  tendency  to  recur : 
a  palate,  looking  healthy  to-day,  will  assume  to-morrow  an  indo- 
lent relaxed  type,  becoming  semi-yellowish ;  some  point  or  other 
will  take  on  a  fatty  look,  and  in  a  few  hours  break  down  into  an 
ulcer.  This  may  recur  a  dozen  times;  the  explanation  is  to  be  looked 
for  in  the  systemic  condition.  Such  recurrence  of  the  ulceration  may 
extend  over  a  period  of  six  or  eight  months,  in  defiance  of  the  most 
careful  attention.  I  have  certainly  found  it  so  in  my  own  practice, 
and  imagine  it  to  be  a  common  experience.  The  salt-bath  will  be  found 
in  these  cases  invaluable,  affording,  as  it  does,  an  increased  vitality. 

ExANTHEMATOus  Xecrosis. — Necrosis  occurring  as  a  sequel  to 
the  exanthematous  fevers,  belongs,  so  far  as  I  know,  exclusively  to 
the  dentitional  period.     Two  cases  in  my  own  practice  occurred 


NECROSIS.  323 

about  the  sixth  year  of  age,  and  were  both  attendant  on  attacks  of 
measles.  The  accompanying  view  is  from  a  photograph  of  pieces 
constituting  the  full  half  of  the  lower  jaw,  which  I  removed,  some 
two  years  back,  from  the  mouth  of  a  little  German  boy. 

Fig.  65. — Sequestrum  after  Measles. 


A  clinical  report  of  this  case,  made  and  published  at  that  time  by 
Dr.  H.  L.  Gilmore,  may  have,  to  the  student,  some  instruction  in 
it,  as  it  describes  the  practice  pursued. 

"  Our  first  case  this  afternoon  is  the  little  German  boy  seen  by 
you  at  a  previous  clinic.  When  last  exhibited,  I  told  you  that  we 
could  scarcely  hope  to  save  his  life,  so  depressed  was  his  general 
health  ;  since  then,  however,  a  great  change  is  remarked.  He  has 
been  using  salt-baths  daily,  living  on  the  best  and  most  nourishing 
food,  drinking  lager  beer,  and  taking  iron  and  quinine.  The  parts 
have  been  almost  hourly  syringed,  and  the  ofiFen.sive  and  semi-putrid 
discharge,  instead  of  passing  into  his  stomach,  has  been  kept  washed 
away. 

"  In  the  treatment  of  cases  of  extensive  necrosis  like  this  before  us, 
there  are  three  marked  indications.  The  first  is  to  keep  up  the  life- 
force  of  the  patient.  The  second  is  to  insure  against  deformity,  by 
securing  new  bone,  to  replace  the  dying.  The  thi7-d,  to  get  away 
the  dead  bone  as  soon  as  nature  permits. 

"  The  first  and  second  indications  are  met  on  a  common  principle, 
namely — constitutional  and  local  tonic,  and  stimulating  treatment. 
As  soon  as  we  see  that  the  death  of  the  circumference  of  the  bone  is 
not  to  be  avoided  by  that  preliminary  treatment,  which  applies  to 
the  demands  of  the  inflammation  in  its  acute  stage,  we  at  once  apply 
ourselves  to  saving  the  periosteum  by  a  process  of  enucleation.  We 
introduce,  as  rapidly  as  we  can,  tents  of  cotton  and  sponge  between  the 
bones  and  periosteum,  which,  by  their  expansion,  effect  the  end  de- 
sired, hasten  necessarily  the  death  of  the  denuded  bone,  and  pre- 
serve for  the  repair  the  osteo-genic  power.  Here  will  be  found 
exhibited  the  necessity  for  great  cleanliness,  and  not  unlikely  for 
local  stimulation.     Permanganate  of  potash,  from  3  to  5  grs.  to  the 


324  ORAL  DISEASES  AND   SURGERY. 

ounce  of  water,  will  be  found  an  admirable  disinfectant.  Tincture 
of  iodine,  or  the  tinct.  with  a  small  addition  of  creasote,  is  the  best 
stimulant  I  am  acquainted  with  ;  I  think  the  latter  will  provoke  the 
periosteum  to  effort  when  nothing  else  will, — at  least  this  seems  to 
be  my  personal  experience. 

"As  a  rule,  I  think  new  bone  can  be  made  to  envelop  the  old;  but 
there  are  cases  where  such  a  result  cannot  be  secured.  Such  a  case 
is  the  one  before  us.  I  have  done  everything  possible  for  this  boy, 
but  there  is  no  attempt  at  repair.  An  explanation  is  to  be  found,  of 
course,  in  his  general  condition ;  he  is  a  very  scrofulous  subject. 
His  necrosis  is  the  result  of  an  attack  of  measles.  The  removal  of 
the  dead  jaw  must,  of  course,  to  some  extent  deform  him, — that  is,  if 
we  are  not  mechanics  enough  to  invent  some  antagonizing  piece  of 
apparatus,  to  be  worn  until  a  cure  is  effected.  If  the  boy  was  able 
to  bear  a  longer  drain  upon  his  system,  I  would  leave  the  dead  bone, 
and  continue  to  try  to  get  the  envelope  of  new  bone ;  but  this  would 
not  do,  the  drain  must  either  cease,  or  the  lad  must  die.  The  effort 
to  secure  new  bone  could  only  be  continuous  of  what  I  have  been 
doing,  and  it  really  would  seem  as  if  it  were  useless  to  do  in  this 
way  more  than  has  already  been  done. 

"  I  cannot  learn,  with  any  positive  certainty,  exactly  how  long  this 
disease  has  been  going  on;  the  parents  say  several  months.  If  you 
get  such  a  patient  cured  within  a  year  you  will  have  managed  your 
case  very  well, — the  rule  always  being  to  wait  for  the  reparation  of 
the  bone,  hastening  and  advancing  the  exfoliation  by  any  non- 
operative  means  in  reason,  but  never  anticipating  the  natural  cure 
by  section  with  saw,  knife,  or  chisel. 

"  Having  then  done  for  this  boy  all  in  our  power,  and  having,  as 
the  result,  a  dead  half-jaw,  which,  from  the  irritation  kept  up  by 
its  presence,  is  day  by  day  injuring  him,  there  is  nothing  left  to  be 
done  but  its  removal,  and  this  I  will  now  proceed  to  effect  in  your 
presence. 

"When  I  touch  the  bone  with  a  probe  I  recognize  it  as  dead  bone. 
Dead  bone  has  a  peculiar  feel  when  struck :  it  emits  a  dull  leaden 
sound,  has  a  rough  surface,  and  can  be  recognized  as  being  more  or 
less  necrosed.  When,  however,  the  lower  jaw-bone  is  dead,  and  is 
not  enveloped  by  a  gutter  of  new  bone,  it  is  found  held  very  firmly 
in  its  place  by  the  surrounding  indurated  soft  parts.  This  is  often- 
times a  source  of  great  deception,  leading  to  the  injurious  inference 
that  the  bone  is  not  exfoliated,  and  as  a  consequence,  permitting  its 
undue  retention.     This  is  the  condition  in  the  present  case.     To 


NECROSIS.  325 

satisfy  myself,  I  introduce  this  delicate  hook  beneath  the  bone.  In 
lifting  with  it  I  find  the  bone  yields  with  a  kind  of  spring,  as  if  I 
were  pulling  against  cartilage.  This  satisfies  me  that  the  bone  is 
loose,  and  needs  only  to  be  freed  from  this  indurated  ring  to  be  capable 
of  a  comparatively  easy  removal.  We  will  now  etherize  the  boy, 
and  lay  this  ring  open  as  far  as  the  coronoid  process.  Not  forgetting, 
however,  in  the  incision,  the  relation  of  the  internal  carotid  artery 
to  this  process 

"  The  bone  extracted  included  both  the  coronoid  and  condyloid 
processes,  and  the  body  as  far  forward  as  the  incisor  tooth.* 

"After  the  operation,  there  was  directed  one-eighth  of  a  grain  of 
acetate  of  morphia.  Lead-water  and  laudanum  to  the  face,  and  fre- 
quent syringings  with  medicated  water." 

Other  Exanthems. — Necrosis  from  other  of  the  exanthems  I 
have  not  personally  happened  to  meet  with,  although  from  scarlet 
fever  it  is  much  the  most  frequent;  while,  as  well,  a  reasonable 
number  of  cases  are  reported  from  smallpox.  From  measles  I  have 
had  three  cases. 

Mercurial  Necrosis. — Ostitis,  and  exfoliation  from  the  undue 
use  of  the  mercurials,  are  so  common  as  to  have  been  observed  by 
every  practitioner.  The  history  of  each  case  is  that  of  a  progressive 
pytalism  :  first,  the  coppery  taste,  enlargement  of  the  tongue,  saliva- 
tion; second,  soreness  of  the  teeth,  recession  and  loosening  of  the 
gums,  discharge  of  offensive  pus,  exfoliation.  Many  interesting 
cases  of  this  condition  have  come  under  my  own  notice,  some  of 
which  are  alluded  to  in  other  parts  of  this  volume.  Generally,  the 
cases  will  be  found  associated  with  children,  induced  by  the  great 
vascularity  and  susceptibility  of  the  bones  at  the  dentitional  period. 
I  judge,  from  my  own  observations,  that  a  practitioner  in  the  use  of 
this  medicine  must  look,  for  a  rule  of  practice,  in  every  individual 
child  he  may  have  occasion  so  to  treat. 

In  the  treatment  of  mercurial  ulitis,  I  have  called  attention  to 
a  .practice  by  free  scarification  and  the  local  use  of  iodine.  Many 
cases  of  threatened  necrosis  have  been  by  these  means  aborted,  but 
very  great  care  is  to  be  exercised  that  the  low  vital  force  be  not 
still  further  depressed.  (See  Chapter  on  Ulitis.) 

The  treatment  of  ulitis  is  the  treatment  of  ostitis. 

In  the  special   treatment  of  a  sequestrum,  it   is   to   be    looked 


*  Two  years  later  I  saw  this  patient — the  deformity  was  very  trifling,  and 
he  certainly  seemed  to  use  his  jaw  without  inconvenience. 


326  ORAL  DISEASES  AND  SURGERY. 

upon  as  a  matter  of  much  importance  that  the  dead  piece  be  de- 
tached by  nature  alone,  assisted  by  the  surgeon  only  as  in  other 
paragraphs  described.  Particularly  does  this  seem  important  in 
the  young  jaw,  as  thus  it  may  happen  that  we  shall  not  disturb, 
unnecessarily,  the  germs  of  developing  teeth. 

Much  stress  has  been  laid  by  some  practitioners  on  the  preserva- 
tion of  such  teeth  as  are  associated  with  the  sequestrum,  and  advice 
given  that  incisions  be  made  through  the  soft  parts  that  shall  allow 
the  bone  to  be  drawn  away  from  the  loosened  teeth.  Such  treat- 
ment can  certainly  only  apply  to  very  few  and  peculiar  cases.  As 
a  rule  of  practice,  I  am  confident  it  must  be  found  of  little  significa- 
tion. 


CHAPTER    XXII. 


THE  TUMORS  OF  THE  MOUTH. 


In  entering  on  a  consideration  of  the  tumors  of  the  mouth  and 
jaws,  we  are  to  recognize  and  appreciate  certain  general  governing, 
or  underlying  principles. 

1st.  Tumors  of  this  location,  alike  with  those  situated  in  other 
parts,  are  analogous  and  heterologous,  or  benign  and  malignant. 

2d.  The  maxillary  bones,  because  of  their  great  vascularity  and 
exposure  to  sources  of  irritation,  are,  perhaps,  more  disposed  to  enter 
on  pathological  conditions  than  any  other  of  the  ossa  corporse. 

3d.  The  principal  source  of  irritation  to  the  maxillary  bones  is  to 
be  found  in  diseased  teeth. 

4th.  Malignant  tumors  of  these  bones  are  perhaps  to  be  esteemed 
only  as  local  exhibitions  of  an  existing  cachexia.  The  character  of 
the  diseased  action,  the  result  of  local  injury,  will  be  determined  by 
the  diathesis. 

5th.  Tumors  of  the  maxillary  bones  which  may,  with  most  assur- 
ance, be  looked  on  as  benign,  are  the  encysted,  the  common  inflam- 
matory, and  the  exostoses. 

6th.  Those,  the  character  of  which  may  be  esteemed  doubtful, 
and  malignant,  are  the  sarcomatous — fibro-plastic — and  the  carcino- 
matous. 

7th.  There  is  not,  unfrequently,  such  a  running  together,  so  to 
speak,  of  the  appearances  presented  by  benign  and  malignant 
growths  as  to  render  distinctive  diagnostic  signs  only  appreciable, 
if  indeed,  at  all  so,  to  the  very  experienced.  Certain  general  features, 
however,  associate  commonly  with  the  two  lesions,  which  are  to  be 
studied  with  the  greatest  advantage. 

1.  Benign  tumors,  it  will  be  found,  are  mostly  to  be  referred  to 
some  cause,  and  are  apt  to  be  in  proportion  to  this  cause.  They  are 
found  circumscribed  by  healthy  structures,  lymph  in  a  greater  or 
lesser  state  of  organization  surrounding  and  marking  their  line  of 
extent. 

2.  They  do  not  seem  to  have  other  than  the  most  innocent  rela- 

(327) 


328  ORAL  DISEASES  AND  SURGERY. 

tion  with  adjoining  organs,  any  disturbance  of  function  from  their 
presence  being  referable  to  mechanical  rather  than  to  pathological 
causes. 

3.  In  structure  they  are  found  homologous  ;  they  represent  more 
or  less  truly  the  parts  to  which  they  are  allied,  and  possess  scarcely 
any  other  than  a  single  formative  capacity.  They  do  not  defy  con- 
stitutional treatment,  but  are  more  or  less  influenced  by  it.  If 
removed  by  the  knife,  they  do  not  return. 

1.  Malignant  tumors  are,  on  the  contrary,  not  at  all  in  proportion 
to  a  cause  which  may  seem  to  be  the  provocative.  They  are  not 
healthily  circumscribed,  but  their  elementary  particles  are  most  apt 
to  be  found  infiltrated,  inserted,  or  diffused  in  the  interspaces  and 
cavities  of  the  tissues  in  which  they  lie.  They  are  associated  with 
a  cachexia  which  is  not  unfrequently  more  marked  than  the  local 
disorder.  Thus  the  vis  vitse  is  not  unfrequently  so  prostrated  that 
the  patient  is  found  dying  with  systemic  depression.  (The  common 
idea  that  the  cancer  patient  has  the  color  of  a  cold  buckwheat  cake 
is  not  entirely  without  truth  ;  it  is  not  always  seen,  but,  I  believe, 
exists  in  a  proportion  of  cases.) 

2.  A  marked  diagnostic  sign  (perhaps  the  most  marked)  of  a  can- 
cerous tumor,  is  the  effect  of  its  presence  on  surrounding  glandular 
structures ;  these  becoming  enlarged  and  indurated,  and  remaining  so. 

3.  The  removal  of  any  supposed  cause,  or  the  removal  of  a  cancer- 
ous tumor  itself,  will  not  effect  a  cure. 

4.  True  cancer  seems  not  amenable  to  any  constitutional  treat- 
ment. There  are,  I  think,  the  best  of  reasons  for  inferring  that  all 
reports  of  cases  cured  have  originated  in  mistaken  diagnosis. 

5.  Malignant  tumors  have,  through  the  cachexia,  a  varying  form- 
ative capacity:  they  multiply,  and,  as  it  were,  propagate  themselves; 
if  one  is  removed,  a  second  comes  to  take  its  place,  either  appearing 
in  the  site  of  removal  or  in  some  other  locality. 

In  the  study  of  these  marked  and  distinctive  features,  the  practi- 
tioner will  find  himself  led  to  perceive  the  first  and  most  important 
of  the  differences  in  maxillary  tumors;  he  will  be  led  also  to  ap- 
preciate the  fact  of  a  relationship  which  is  to  compel  him  to  look  on 
certain  of  the  homologous  growths  as  not  being  entirely  devoid  of 
danger;  he  will  also  find  data  for  judgment  which  will  serve  him  in 
every  individual  case. 

Benign  Tumors. — For  convenience  of  study,  we  will  class  under 
this  head  the  cystic  growths,  the  common  inflammatory,  and  the 


TUMORS   OF   THE  MOUTH.  329 

exostoses,  premising  that,  as  the  first  class  is  concerned,  we  shall 
have  occasion  further  on  to  recognize  exceptions. 

Cystic  Tumors. — The  cystic  tumors  of  the  mouth  are  of  two 
kinds :  simple  and  compound.  The  simple  cysts  seem  to  be  mere 
expansions  of  the  outer  plate  of  the  bones — wind-bags,  as  the  older 
writers  called  them ;  a  fair  expression  to  convey  the  idea  of  their 
character,  yet  requiring  considerable  qualification.  The  second  class, 
the  compound,  are  cysts  containing  peculiar  contents,  which  con- 
tents have  induced  the  cyst  and  constitute  the  lesion  to  be  studied; 
of  the  latter  class,  the  odontocele  is  by  far  the  most  common,  and 
such  tumors  vary  from  the  simple  encystment  of  a  perfected  tooth 
to  some  perverted  development  which  requires  the  nicest  discern- 
ment of  the  microscope  to  investigate.  Under  the  head  of  cystic 
tumors  might  also,  with  propriety,  be  noticed  those  occasional  ex- 
pansions of  the  walls  of  the  maxillary  sinus  dependent  on  engorge- 
ments. 

The  Simple  Cyst. — All  writers  on  surgery  have  remarked  the 
existence,  in  the  mouth,  of  this  form  of  tumor.  A  simple  expansion 
of  the  bone  with  varying  fluid  or  gaseous  contents  ;  different  authors 
differently  describe  and  name  them.  The  term  spina  ventosa  is, 
perhaps,  about  the  most  unmeaning  that  has  been  applied.  As 
I  know  them,  their  history  may  be  written  as  follows:  there  is 
first  remarked  on  the  side  of  the  jaw,  either  superior  or  inferior  (no 
preference  seems  to  exist),  a  slight  flattened  enlargement ;  this  in- 
creases slowly,  until  the  swelling  reaches  the  size  of  half  a  hickory 
nut;  they  are  seldom  seen  larger.  No  pain  attends  the  growth, 
and  outside  of  the  mental  disquietude  necessarily  induced,  no 
functional  or  other  constitutional  disturbance  attends.  The  slow- 
ness of  growth  is  such  that  it  requires  from  one  to  three  years  to 
reach  the  size  alluded  to.  This  tardiness,  absence  of  pain,  and 
constitutional  disturbance  constitute  marked  diagnostic  signs.  An- 
other sign,  and  one  on  which  every  writer  with  whom  I  am  ac- 
quainted lays  particular  stress,  is  the  giving  forth,  on  pressure, 
of  a  parchment-like  crackling;  with  this  last  I  seem,  however, 
to  have  had  a  peculiar  experience,  for  while  I  have  treated  quite  my 
share  of  such  cases,  it  has  not  been  my  fortune  to  find  such  crackling 
sound  in  any  single  one  of  them,  and  while  of  course  it  would  ill  be- 
come any  individual  to  assert  that  such  a  crackling  never  can  be 
heard,  yet  I  would  impress  that  such  a  sign  is  not  by  any  means 
an  ever-present  indication,  consequently  is  not  to  be  given  the 
heed  demanded  for  it.     In  most  of  these  tumors  on  which  I  have 


330  ORAL  DISEASES  AND  SURGERY. 

operated,  septi,  more  or  less  ia  number,  have  been  found  supporting 
the  vault ;  with  the  existence  of  such  pillars  it  is  plainly  enough 
seen  that  yielding  would  be  out  of  the  question,  so  that  the  practi- 
tioner is  not  to  be  deceived  by  the  firm  character  of  the  tumor.  The 
gum  covering  such  cystic  tumors  is  always  perfectly  normal, — no 
congestion,  nor  anything  indicating  its  implication ;  a  matter  im- 
portant to  observe,  as,  should  the  diagnosis  be  in  anywise  obscured, 
the  practitioner  would  have,  at  least,  the  satisfaction  of  feeling  a 
tolerable  assurance  as  to  the  benign  character  of  the  gi'owth  as  well 
as  to  its  non-acute  character. 

Of  the  number  of  cysts  of  this  class  that  I  have  seen,  every  one 
have  been  situated  in  the  outer  or  vestibular  walls  of  the  bones. 
Why  they  should  be  so,  or  indeed  whether  it  is  always  the  case,  I 
do  not  know.     I  only  offer  my  own  experience. 

A  diagnosis  made  out,  the  cure  is  very  simple.  A  common 
treatment,  and  one  generally  practiced,  because  of  its  little  trouble, 
is  to  make  a  crucial  incision  through  the  body  of  the  tumor,  and, 
breaking  up  such  septi  as  may  exist,  stuff  the  cavity  with  lint 
saturated  with  the  tincture  of  iodine ;  this,  if  there  is  no  foreign 
body  in  the  cavity,  as,  for  instance,  the  root  of  a  dead  tooth,  will 
invariably  cause  the  base  to  throw  out  granulations,  and  thus 
obliterate  the  cyst. 

Another  mode  not  unfrequently  resorted  to,  is  to  dissect  from  the 
tumor,  in  flap-form,  the  overlying  gum,  and  with  a  chisel  cut  away 
the  vault  of  the  cyst ;  the  parts  are  then  carefully  syringed  and  the 
flap  laid  back.  This  latter  operation  requires  much  more  time, 
much  more  skill,  and  gives  much  more  pain.  The  first  is  not  nearly 
so  objectionable  to  the  patient,  and  is  equally  as  effectual. 

Concerning  hemorrhage,  little  anxiety  need  be  felt.  I  never  found 
it  give  any  trouble  ;  it  may  be  necessary  to  syringe  the  cavity  with 
a  little  alum-water,  or  some  other  astringent,  but  even  this  is  not 
commonly  needed. 

Caf^e  — .  Mrs.  C ,  aged  about  twenty-one,  applied  to  me,  some 

two  years  back,  for  treatment  of  a  tumor  occupying  the  canine  fossa 
of  the  left  superior  maxillary  bone.  The  growth  had  been  eighteen 
months  in  progress ;  was  about  the  size  of  half  a  walnut,  perfectly 
solid  to  the  touch,  painless,  and  entirely  healthy-looking ;  the  great- 
est disquietude  of  the  patient  being  mental,  her  mother  having  died 
from  scirrhous  cancer. 

Diagnosis  — Simple  cyst. 

Treatmept. — Crucial  incisions  were  made  ;  several  delicate  septi 


TUMORS  OF   THE  MOUTH.  33I 

of  bone,  which  the  cuts  discovered,  were  broken  up  ;  the  cyst  was 
injected  for  the  first  three  days  with  weak  stimulating  liquors.  No 
inflammation  developing,  tufts  of  cotton  were  saturated  with  tinct. 
of  iodine,  and  the  cyst  stuffed.  In  one  week  the  site  of  the  cavity 
was  occupied  by  healthy  granulations  ;  in  three  weeks  the  patient 
was  entirely  cured,  and  left  the  city  for  her  home  in  an  adjoining 
State. 

Case  — .  About  nine  months  back,  a  German  woman  applied  with 
a  cystic  tumor,  similar  to  the  above  ;  it  was  certainly  as  unyielding 
as  solid  bone.  This  tumor  was  treated  by  making  a  crucial  incision 
through  the  soft  parts  alone,  the  flaps  were  dissected  off,  and  the 
cyst  being  exposed,  was  cut  away  with  a  chisel-shaped  instrument. 
The  flaps  fell  naturally  into  the  cavity,  and  were  left,  even  without 
a  stitch,  to  take  care  of  themselves.  The  cure  was  complete  in  about 
a  week. 

There  is  a  tumor  of  the  soft  parts  of  the  jaw — cystic,  but  not 
osseous — which  is  not  to  be  confounded  with  the  class  just  de- 
scribed. Both  look,  occasionally,  precisely  aUke,  but  the  latter 
yields  under  pressure,  as  any  tumor  of  a  semi-soft  part  would 
yield.  Mr.  Paget  alludes  to  such  a  disease  in  his  lectures  on  Surgi- 
cal Pathology,  pages  342-3.  "A  woman,"  he  says,  "thirty-eight 
years  old,  was  under  my  care  in  1849,  in  whom,  at  first  sight,  I 
could  not  but  suppose  something  was  distending  the  antrum,  so 
closely  was  deformity  of  the  face  due  to  such  disease  imitated.  But 
the  swelling  was  soft  and  elastic,  and  projected  the  thin  mucous  mem- 
brane of  the  gum  of  the  upper  jaw,  like  a  half-empty  sac.  I  cut 
into  this  sac,  and  let  out  nearly  an  ounce  of  turbid,  brownish  liquid, 
sparkling  with  crystals  of  cholesterine.  The  posterior  wall  of  the 
cyst  rested  in  a  deep  excavation  on  the  surface  of  the  alveolar  border 
of  the  upper  jaw ;  an  adaptation  of  shape  attained,  I  suppose,  as 
the  result  of  the  long-continued  pressure  of  the  cyst,  which  had  ex- 
isted six  years." 

Mr.  Paget  also  makes  mention  of  a  young  man  under  his  care  with 
a  similar  tumor,  which,  he  says,  was  the  result  of  an  injury  to  the 
gum  or  alveolar  border  six  months  previously.  In  neither  of  these 
cases,  says  he,  could  I  find  any  disease  of  the  maxillary  bone.* 
Their  origin,  so  far  as  my  experience  goes,  is  in  a  diseased  tooth-fang. 


*  These  cysts  I  have  several  times  met  with.     They  are  what  may  be 
termed  cold,  or  non-acute  alveolar  abscesses. 


332  ORAL  DISEASES  AND   SURGERY. 

I  do  not  know  what  so  close  an  observer  as  Mr.  Paget  means  when 
he  says  he  could  find  no  disease  of  the  bone.  There  ought  to  be  at 
best  one  little  shotlike  hole  somewhere  about  the  surrounding  osse- 
ous wall ;  at  any  rate,  such  is  the  history  as  I  have  met  with  them. 

A  succeeding  case,  which  Mr.  Paget  mentions,  seems  to  prove  the 
tumors  are  the  same  as  I  refer  to.  "A  lady,"  he  says,  "  had  a  small 
cvst  of  this  kind,  which  had  existed  twenty-seven  years,  filling  and 
discharging  almost  daily.  It  had  its  origin  in  a  blow,  by  which  the 
two  median  incisors  were  loosened."* 

A  few  winters  back  a  physician  from  Kentucky  applied  to  me  for 
treatment  of  a  tumor  of  the  lower  jaw,  which  had  existed  for  over 
two  years  ;  it  had  the  feel  of  a  fibroid  body.  This  gentleman,  with 
the  imaginative  qualities  common  to  the  practitioner,  when  he  him- 
self becomes  the  patient,  had  succeeded  in  satisfying  himself  of  the 
cancerous  character  of  his  trouble.  An  incision  through  the  growth 
demonstrated  it  to  be  a  cold  alveolar  abscess.  In  a  single  week  he 
was  cured ;  the  treatment  required  was,  simply  keeping  patulous  the 
incision,  and  using  a  few  stimulating  injections. 

In  the  Western  Medical  Journal,  vol.  x.  pages  185  to  228,  is  a 
learned  article  from  the  pen  of  Prof  Gross,  on  "  Excision  of  the 
Maxillary  Bone."  In  the  course  of  this  paper,  he  makes  the  following 
allusion  to  the  osteoid  cysts  : 

"  The  sero-cystic  tumor  of  the  upper  jaw  is  uncommon,  and,  for- 
tunately, devoid  of  malignancy.  Its  usual  site  is  the  alveolar  pro- 
cess, where  it  has  been  known  to  attain  the  volume  of  a  hen's  egg, 
and  even  of  a  large  orange.  It  is  composed  of  a  thin,  semi-trans- 
parent, or  slightly  opaque  bag,  occupied  by  a  colorless  or  sanguineous 
fluid,  or  by  a  glazy,  mucilaginous  substance.  Sometimes,  though 
rarely,  there  are  two  such  cysts,  either  closely  connected  together  or 
separated  by  a  kind  of  osseous  septum.  The  bone  around  the  tu- 
mor is  expanded  into  a  thin,  elastic,  crackling,  parchment-like  shell, 
and  is  easily  penetrated  by  a  sharp  instrument,  the  puncture  giving 
vent  to  the  characteristic  contents  of  the  cyst."  This,  Prof.  G. 
thinks,  is  the  best  diagnostic  sign  of  the  morbid  growth.  "  The  gen- 
eral health,"  he  remarks,  "remains  unaflFected  in  the  disease,  which 
is  always  tardy  in  its  progress,  and  m  anifests  no  disposition  to  ex- 
tend among  the  adjacent  structures."  Where  any  doubt  exists  as  to 
the  real  nature  of  the  case,  he  advises  a  resort  to  the  exploring 
needle,  which  he  says  will  usually  at  once  dispel  it. 


*  This  history  is  that  of  chronic  alveolar  abscess  in  every  particular. 


TUMORS    OF   THE  MOUTH.  333 

Prof.  G.  thinks  it  is  not  often  this  tumor  calls  for  removal  of  the 
affected  bone  ;  he  gives  it  as  his  experience  that,  in  general,  it  will 
suffice  to  puncture  it  occasionally  with  a  small  trocar,  to  evacuate 
'  its  contents,  the  escape  of  which,  he  says,  he  has  found  to  be  often 
followed  by  the  rapid  contraction  and  final  obliteration  of  the  sac. 
Where  there  is  a  strong  tendency  to  reaccumulation,  he  recommends 
that  a  large  opening  should  be  made,  and  tincture  of  iodine  thrown 
in,  to  promote  the  object  in  view. 

The  cystic  tumor  of  Paget  is,  I  presume,  the  same  disease  of  the 
jaw  to  which  the  name  spina  ventosa  was  originally  applied — spina 
to  express  pain  resembling  the  pricking  of  thorns,  and  ventosa  to 
indicate  that  the  tumor  was  filled  with  wind.  The  term  is  not  yet 
obsolete,  but,  like  epulis,  is  employed  so  freely  that  no  one  now 
knows  what  it  means. 

Recapitulatory. — The  cystic  tumor  is  an  osseous  cyst  of  the  jaw, 
which  forms  just  beneath  the  outer  plate  of  the  alveolar  process, 
and  has  its  cyst  as  a  result  of  the  expansion  and  attenuation  of 
the  external  lamina. 

It  is  seen  as  a  bulb  on  the  alveolar  face,  is  commonly  met  with 
about  the  size  of  half  a  hickory  nut,  the  gum  which  covers  it  is 
perfectly  natural  in  appearance.  It  may  yield  to  the  touch,  or  it 
may  not. 

The  most  satisfactory,  and,  withal,  perfectly  safe  means  of  diag- 
nosis, is  to  pass  a  keen  scalpel  or  lancet  into  the  growth  ;  if  it  is  the 
tumor  we  describe,  the  knife  will  give  to  the  touch  the  sense  of 
having  passed  through  a  bony  wall  into  a  cyst. 

The  septi,  alluded  to  as  existing  in  the  simple  cysts,  are  occa- 
sionally replaced  by  what  is  known  as  a  multilocular  cyst, — that  is 
to  say,  a  common  tumor  is  made  up  of  many  cysts.  As  these 
cysts  increase  in  number,  so  the  complexity  of  the  tumor  increases ; 
and  it  may  be  that  we  will  feel  ourselves  compelled  to  decide  that  a 
cure  is  best  promised  by  the  complete  extirpation  of  all  the  portion 
of  bone  implicated. 

Examination  will  reveal  that  these  cysts  vary  much  in  charac- 
ter ;  sometimes  they  will  be  discovered  unlined  and  empty,  some- 
times a  kind  of  serum  will  be  found  to  fill  them.  Again,  as  in  a 
case  operated  on  by  myself,  they  will  be  found  filled  by  a  pulpy, 
liver-colored,  turgid,  lining  membrane.  This  is  the  class  that  afBli- 
ates  with  what  is  to  be  described  as  cysto-sarcoma ;  as  these  tu- 
mors pass  from  simplicity  in  their  expression,  we  come  to  class 
them  with  the  latter  disease,  and  to  esteem  them  as  belonging  to 


334 


ORAL  DISEASES  AND   SURGERY. 


doubtful  growths.  It  has  been  my  experience  that  as  such  tumors 
increase  hi  complexity  they  discolor  the  overlying  mucous  mem- 
brane, so  that  as  this  membrane  is  changed,  we  judge  the  growths 
allied  to  cysto-sarcoma. 

The  Compound  Cyst.— In  this  class  of  the  cystic  growths  we 
have  the  running  together  of  the  benign  and  malignant  conditions 
which  make  so  necessary  to  their  proper  appreciation  that  general 
comprehension  of  the  subject  alluded  to  on  a  former  page.  Without 
doubt  the  dentigerous  cyst  is  by  far  the  most  common  type  of  the 
compound  oral  cystic  growths;  but  in  the  malignant  cysts  teeth 
are  sometimes  found,  or  some  dental  association  is  seen  to  exist ; 


Fig.  66. — Odontocele. 


hence,  not  to  confuse  the  subject  in  the  outstart,  we  are  to  under- 
stand here  that  in  the  use  of  the  term  compound  cyst,  we  mean 
benign  cysts  which  contain  irregularly-developed  teeth  or  dental 
tissue. 

A  common  odontocele  is  the  simplest  form  of  an  osteo-dental 
tumor ;  it  may  present  itself  in  any  part  of  the  maxillary  structure, 
and  what  is  of  much  consequence  to  remember,  may  have,  as  the 
primary  lesion,  a  supernumerary  tooth. 

Illustrations. — A  young  lady,  aged  sixteen,  presented  herself, 
having  a  tumor,  intramaxillary,  evidently,  occupying  the  anterior 
left  side  of  the  hard  palate.     Her  exact  condition  is  as  follows  :  she 


TUMORS   OF   THE  MOUTH.  335 

has  never  had  a  single  tooth  of  the  permanent  set  extracted.  Yet 
she  lacks,  to  make  up  the  complement  common  to  her  age,  the  canine 
of  the  affected  side.  The  tumor  is,  of  course,  an  odontocele,  or  at 
least  so  great  is  the  probability  of  such  being  its  character,  con- 
sidering the  absence  from  the  dental  arch  of  the  tooth,  that  any  sur- 
geon would  feel  justified  in  founding  a  proposed  operation  on  such 
conviction. 

In  1861  the  following  very  interesting  case  o'f  odontocele  came 
under  my  observation.  The  patient,  desiring  a  set  of  artificial  teeth, 
had,  about  a  year  previous,  had  extracted  all  the  teeth  of  the  upper 
jaw,  and,  as  is  customary,  had  been  dismissed  for  a  period  of  some 
four  months,  not  desiring  to  wear  a  temporary  denture.  At  the  end 
of  this  time  the  impression  of  his  mouth  had  been  taken,  the  parts 
being  in  a  good  healthy  condition.  The  teeth  were  made,  placed  in 
position,  and  worn  with  entire  comfort  for  a  period  of  several 
months. 

About  eight  weeks  before  presenting  himself  to  my  notice,  these 
artificial  teeth  were  found  to  be  getting  loose,  as  if  from  some  pro- 
jection at  the  right  border  of  the  myrtiform  fossa.  Applying  to  his 
dentist,  surprise  was  expressed  at  the  occurrence,  and  advice  given 
that  the  further  progress  of  the  case  should  be  awaited.  At  this 
period  the  gums  were  more  or  less  congested,  and  were  putting  on 
quite  an  angry  appearance ;  a  few  days  later  a  fistule  formed.  His 
dentist,  confident  that  no  portion  of  the  roots  of  any  of  the  teeth 
had  been  left  in  the  alveolus,  now  dismissed  the  case,  advising  him 
to  seek  surgical  assistance.  In  this  condition  he  came  under  my 
observation. 

The  case  presented  the  following  features  :  much  engorgement  of 
all  that  portion  of  the  gum  and  lip  covering  the  incisive  and  ca- 
nine fossas,  and  which  extended  in  a  triangular  direction  to  the  inner 
canthus  of  the  right  eye,  much  soreness  on  pressure  over  all  the 
affected  parts,  the  fistule  discharging  thin,  and  occasionally  bloody 
pus. 

Examination  with  the  probe  gave  the  impression  that  it  struck 
against  the  root  of  a  tooth,  and  which  would  certainly  have  influ- 
enced the  making  up  of  the  diagnosis  if  experience  had  not  assured 
me  that  no  tooth  could,  under  ordinary  circumstances,  have  had  a 
fang  extending  such  a  length. 

Deducing  from  the  conditions  present  the  imperative  necessity  for 
an  operation,  and  the  patient  willingly  acceding  to  the  conclusion, 
the  followimg  course  was  pursued.     The  patient  was  etherized  ;  an 


336  ORAL  DISEASES  AXD   SURGERY. 

assistant,  having  sponge  and  water  at  his  side,  took  charge  of  the 
lower  jaw  and  lip.  A  second  assistant  steadied  the  head  and  held 
the  superior  lip  well  out  of  the  way  of  the  knife. 

The  parts  being  thus  very  fairly  exposed,  a  pointed  and  somewhat 
delicate-bladcd  bistoury  was  passed  through  the  superior  fleshy 
boundary  of  the  canine  fossa  to  the  inner  canthus.  To  my  surprise, 
it  passed  not  only  through  the  soft  parts,  but  in  the  return  cut  sunk 
readily  into  the  bone.  A  first  flap  was  now  dissected  posteriorly 
from  the  dead  mass :  a  second  was  bounded  mesially  by  the  nasal 
bone,  ala,  and  left  prominence  of  the  myrtiform  fossa.  The  blood 
being  sponged  away,  I  discovered,  lying  in  the  very  center  of  the 
carious  bone,  a  cuspid  tooth  of  ordinary  size  and  development,  the 
apex  being  in  immediate  relation  with  the  floor  of  the  orbit. 

That  this  tumor  had  existed  for  a  long  time  is  not  of  course 
to  be  doubted,  but  it  excited  the  attention  of  the  patient  only  on  the 
setting  up  of  acute  inflammatory  action.  This  inflammation  soon 
destroyed  the  integrity  of  the  vault  of  the  cyst;  hence  the  softened 
carious  state  in  which  I  found  it.  The  interest  associated  with  the 
case  lies  in  the  absence  of  all  the  teeth,  and  the  consequent  loss  of 
data  for  the  diagnosis. 

Osteo-dental  tumors  dependent  on  the  development  of  supernu- 
merary teeth  are  quite  common  ;  they  are  generally  easily  recognized 
from  their  position  and  size,  being  never  larger  than  an  ordinary  pea, 
and  mostly  situated  in  some  part  of  the  palatine  processes  of  the 
superior  maxillae.  Any  obscurity,  however,  in  these  tumors  is  read- 
ily dispersed  by  thrusting  a  bistoury  or  exploring  needle  into  them. 
The  dental  surgeon  particularly  would  remark  from  the  sense  of 
touch  whether  or  not  the  contents  is  tooth  substance. 

Osteo-dental  tumors  not  unfrequently  have  as  their  contents  un- 
developed teeth.  Only  a  few  days  back  I  saw  a  couple  of  bicuspid 
crowns,  evidently  long  dead,  which  had  been  removed  from  one  of 
these  oral  compound  cysts. 

Such  osteo-dental  tumors,  then,  as  just  illustrated,  may  be  viewed 
as  the  most  simple  of  these  compound  cysts.  Another  class,  the 
complex  osteo-dental  cyst,  may  now  claim  attention.  No  better 
illustration  of  this  class  of  tumor  can  be  found  on  record,  perhaps, 
than  in  the  memoir  of  the  Guadeloupe  banker's  son,  by  M.  Forget, 
presented  to  the  French  Academy,  and  so  ably  and  happily  repub- 
lished in  English  some  years  back  by  the  publishers  of  the  Dental 
Cosmos.     As  the  illustrations  and  text  are  still  in  possession  of  the 


TUMORS   OF  THE   MOUTH.  337 

journal,  the  reader  interested  in  the  subject  cannot  do  better  than 
give  them  most  attentive  consideration,  Avhile  certainly  I  cannot  do 
better  than  by  using  them.  We  preface  by  remarking,  that  by  a 
complex  osteo-dental  tumor  we  mean  a  cyst  containing  some  com- 
plex mass,  which  common  observation,  or  the  microscope,  reveals 
as  being  made  up  of  irregular  developments  of  dental  tissues. 

Observation. — 1.  Osteo-Dental  Tumor,  size  of  a  large  Egg,  en- 
cysted in  the  thick  j^fift  of  the  Inferior  Maxillary — Ulcerous  In- 
flammation of  the  Parietes  of  the  Cyst — Numerous  Ossifluent 
Fistulse — Resection  of  the  left  half  of  the  Body  of  the  Jaxo  and  a 
portion  of  its  Branch — Cured. 

Early  in  May  a  banker,  of  Guadeloupe,  introduced  to  M.  Forget 
his  son,  whom  he  had  brought  to  Paris  with  the  intention  of  sub- 
jecting him  to  the  necessary  surgical  operation  for  the  remedy  of  a 
disease  of  the  inferior  maxilla,  which  had  made  its  first  appearance 
when  the  patient  was  five  years  old. 

History  of  the  Disease. — At  that  period  (five  years),  young  L. 
suffered  from  pains  in  his  left  jaw ;  they  were  for  some  time  inter- 
mittent, then  continuous  and  acute.  When  the  patient  was  seven 
years  of  age,  two  small  healthy  molars  were  extracted,  under  the 
impression  that  they  were  preventing  the  evolution  of  the  second 
teeth.  The  operation  gave  great  relief,  and  the  pain  ceased;  but 
shortly  afterward  a  small,  round,  hard  tumor  appeared  on  the  ex- 
ternal face  of  the  jaw,  near  the  alveoli  of  the  teeth  that  had  been 
removed.  The  tumor  caused  no  suffering  to  the  patient,  and  made 
no  sensible  progress  for  a  period  of  eight  years.  The  whole  of  the 
left  side  of  the  jaw  then  became  tumefied,  and  the  bone,  in  the  lan- 
guage of  the  patient,  broadened  and  rounded.  He  also  observed,  at 
this  time,  that  the  large  molars,  which  were  regularly  developed  on 
the  right  side,  were  wanting  in  the  diseased  part. 

This  morbid  enlargement  was  accompanied  by  frequent  fluxions  of 
the  gums,  cheek,  and  whole  left  side  of  the  face.  The  recurrence  of 
this  fluxion  was  attended  with  great  pain,  and  caused  an  increased 
tumefaction  in  the  soft  parts  to  such  an  extent  that  the  difference 
between  the  sides  of  the  face  became  absolute  deformity. 

In  November,  1854,  a  violent  inflammation  occurred  in  the  base 
of  the  jaw  and  the  cervico-maxillary  region.  Antiphlogistic  treat- 
ment was  employed,  two  applications  of  leeches  were  made,  and  the 
inflammatory  symptoms  decreased,  and,  fifteen  days  afterward, 
purulent  matter  formed  in  the  thick  part  of  the  cheek,  which  opened 
spontaneously,  allowing  the  issue  of  a  large  quantity  of  fetid  pus. 

22 


338  ORAL  DISEASES  AND   SURGERY. 

The  opening  of  the  abscess  became  fistulous,  the  surrounding  tissue 
then  detached,  and,  under  them,  the  bone  was  naked  for  a  very  con- 
siderable extent. 

Present  Condition. — Young  L.,  aged  twenty,  strong,  well  de- 
veloped, with  an  excellent  constitution,  and  health  perfect  in  all 
respects,  excepting  the  local  affection. 

The  disease  appears  externally  in  a  considerable  tumefaction  of 
the  left  cheek,  which  is  more  than  three  times  its  natural  size,  and 
the  tumor  has  caused  a  very  marked  eccentric  development  to  the 
corresponding  maxillary  bone. 

When  the  patient  opens  his  mouth,  which  he  does  without  effort, 
the  whole  left  side  of  the  bone  was  seen  to  resemble  a  large  turkey- 
egg — the  base  of  the  jaw  being  confounded,  without  appreciable  line 
of  deniarkation,  with  the  internal  and  external  faces,  which  describe 
a  very  considerable  curve. 

The  tumor  is  uniform,  without  depressions  or  any  irregular  swell- 
ings upon  the  surface.  It  does  not  yield  to  pressure,  and  no  part 
of  it  gives  that  sound  of  crepitation  which  is  characteristic  of  at- 
tenuation of  the  osseous  tissues.  The  external  swelling  hides  the 
superior  and  lateral  part  of  the  neck ;  the  enlargement  of  the  bone 
has  forced  the  tongue  from  its  true  direction,  and  the  floor  of  the 
mouth  has  been  driven  from  the  left  to  the  right. 

The  alveolar  ridge,  singularly  enlarged,  contains  none  of  the  grind- 
ing teeth,  except  the  first  bicuspid,  which  stands  regularly  in  its 
socket.  The  tissue  of  the  gums  is  dark-red,  and  unusually  thick 
and  hard.  In  a  circumscribed  spot,  about  the  size  of  a  twenty- 
centime  piece,  the  tissue  is  broken,  and  exhibits  an  unequal,  wrinkled, 
grayish  surface,  which  gives  a  dry  sound  when  struck  with  a  metal, 
as  if  the  crown  of  a  tooth  were  hidden  in  the  cavity. 

In  order  to  complete  the  symptomatic  description,  it  is  added  that 
there  are  many  ossifluent  fistulous  openings  at  the  base  of  the  tumor, 
and  much  hypertrophy  and  hardening  of  the  submaxillary  lymphatic 
ganglion. 

The  functional  disorders  arising  from  the  pathological  condition, 
at  first  very  slight,  are  noticed  at  this  stage  as  increasing  every  day: 
embarrassment  of  vocal  utterance,  mastication  painful  and  incom- 
plete, deglutition  effected  with  difficulty,  and  respiration  very  diffi- 
cult every  time  inflammation  is  renewed  in  the  tumor ;  lastly,  the 
patient  suffering  from  two  serious  inconveniences — one,  the  very 
marked  deformity  of  the  face ;  the  other,  the  incessant  flow  of  fetid 
pus,  proceeding  from  the  complicated  fistulae  of  the  osteo-dental  caries. 


TUMORS   OF   THE  MOUTH. 


339 


M.  Forget  here  describes  the  operation,  the  usual  resection.  One 
incident,  however,  should  be  remarked :  in  making  his  anterior  cut 
with  the  chain  saw,  he  alludes  to  coming  in  contact  with  a  tooth 
placed  horizontally  in  the  thick  part  of  the  bone,  precisely  under  the 
alveolus  through  which  he  was  cutting. 

Fig.  67. 


Anatomical  Examination  op  Tumor. — With  the  surrounding 
soft  parts,  it  is  described  as  being  an  exact  ovoid.  The  soft  parts, 
adhering  to  its  external  face,  were  found  marked  with  many  fistular 
passages,  ending  at  inflamed  and  ulcerous  points  of  osseous  tissue. 
This  tissue  was  thin,  soft,  and  depressibJe,  and  perforated  by  two 
orifices  leading  into  the  interior  of  the  cyst,  from  which  exuded  a 
purulent,  viscid,  reddish  liquid.  A  stylet  introduced  into  one  of 
these  passages  was  stopped  by  a  hard  body,  which,  under  percus- 
sion, sounded  like  a  compact  tissue  deprived  of  its  periosteum.  This 
object  was  reached  by  dissecting  off  the  gums,  which,  condensed 
into  a  thick  bed,  formed  a  sort  of  operculum  for  the  upper  part,  com- 
pleting the  cyst  in  which  the  morbid  product  was  situated.    The  dis- 


340 


ORAL   DISEASES  AND  SURGERY. 


section  exhibited  that  the  jaw  from  the  ramus  to  the  premolar  had 
been  changed  into  a  cavity  containing  a  compact,  saxaform,  ovoid 
mass,  the  size  of  a  large  eg^,  grayish,  unequal  surface,  studded  with 
small  tubercles,  surrounded  by  a  bed  of  enamel,  and  completely 
buried  in  the  thick  part  of  the  bone.     (See  Fig.  67.) 

Next,  the  tumor  was  divided  along  its  axis  into  two  unequal  parts, 
each  confined  to  the  corresponding  half  of  the  osseous  cyst  that  was 
comprised  in  the  division.  This  revealed  the  composition  of  the 
tumor :  it  was  formed  of  a  smooth,  glossy,  compact,  homogeneous, 
ivory-like  tissue,  of  a  whitish-brown  color.  In  the  center  of  it  a 
kind  of  regular  disposition  of  its  elements  is  described  as  existing, 
discernible  by  the  naked  eye.     (See  Figs.  68  and  69.) 

Fig.  68. 


Between  the  tumor  and  the  wall  of  the  cyst  was  a  thick,  fibro- 
cellular  tissue,  free  on  the  side  of  the  former,  where  it  covered  the 
whole  intramaxillary  portion,  and  was  joined  to  the  latter  by  fila- 
mental  prolongations  of  a  cellulo-vascular  appearance — these  being 
attached  to  the  numerous  openings  that  covered  the  face  of  the  cyst. 
The  external  surface  of  this  membrane  was  bathed  with  a  muco- 
purulent liquid,  smelling  like  dental  caries. 

At  the  base  and  anterior  extremity  of  the  tumor,  an  indentation 
is  described  fitting  the  crown  of  a  large  molar  that  stood  between  it 
and  the  maxillary  bone.  (See  Fig.  69,  h.)  A  portion  of  the  same 
tooth  caused  a  slight  elevation  on  the  external  face  of  the  jaw.  (Fig. 
68,  c.)     M.  Forget  also  describes  the  tooth  encountered  in  the  oper- 


TUMORS   OF   THE  MOUTH. 


841 


ation.  (Fig.  68,  d.)  Its  location,  as  will  be  seen,  is  directly  beneath 
the  alveolus  of  the  first  molar,  which  is  standing  in  its  true  position. 
(Fig.  68,  e.) 


Fig.  69. 


All  the  teeth,  with  the  exception  of  the  last  two  molars,  it  will 
thus  be  seen,  were  found,  and  the  space  appropriated  for  them  was 
filled  by  the  tumor.  What,  then,  queried  M.  Forget,  could  have  be- 
come of  these  two  great  molars  ?  It  could  not  be,  he  argued,  that 
the  bulbs,  compressed  from  their  very  origin,  had  disappeared  with- 
out leaving  a  single  vestige  of  their  existence.  The  numerous  in- 
stances, he  held,  that  had  occurred  of  the  simultaneous  development 
of  teeth  and  anomalous  productions  in  the  very  center  of  the  maxil- 
lary would  not  allow  him  to  think  of  accepting  such  an  explanation. 
In  all  the  analogous  cases  that  had  fallen  under  his  observation,  the 
teeth  were  of  the  ordinary  dimensions,  and  complete  in  number,  al- 
though removed  from  their  normal  position,  and  sometimes  buried 
even  in  the  morbid  substance  itself. 

Let  us  now,  that  we  may  fully  comprehend  .such  a  class  of  cases, 
pursue  the  study  of  this  particular  one. 

Fig.  61  represents  the  left  half  of  the  body  of  the  inferior  maxil- 
lary bone,  hollowed  into  a  large  cavity,  containing  an  ivory-like, 
bony  tumor. 

d.  Side  view  of  the  alveolar  edge. 

a.  Orifice  of  the  dental  canal  upon  the  surface  of  the  resection  of 
the  bone  in  the  continuity  of  the  ramus. 


342 


ORAL  DISEASES  AND  SURGERY. 


b.  Plane  of  the  cut  iu  front,  showing  the  second  small  molar  which 
was  found  in  it. 

e.  Crown  of  the  first  molar,  in  regular  position. 

Tig.  70. 


Figs.  68  and  69.  The  two  halves  of  the  anatomic  section,  divided 
according  to  its  axis  (osseous  cyst,  and  included  tumor). 

Fig.  68. — c.  Crown  of  great  molar,  seen  through  a  notch  in  the 
outer  wall  of  the  cyst. 

d.  Second  small  molar. 

e.  First  small  molar. 

a  and  b.  Points  of  the  same  wall,  perforated  by  the  prolongation 
of  the  tumor. 

/.  Summit  of  the  most  elevated  of  these. 

Fig.  69. — a.  Interior  aspect  of  the  tumor. 

b.  Great  molar  inverted. 

c  and  d.  Cellulo-fibrous  membrane,  interposed  between  the  osseous 
cyst  and  tumor. 


TUMORS  OF   THE  MOUTH.  343 

Fig.  70.  Microscopical  examination. 

M.  Forget,  in  presenting  this  case  to  the  French  Academy,  re- 
marked that  it  was  a  duality  of  anatomical  and  pathological  lesion, 
so  rare,  that  after  the  strictest  research,  he  was  led  to  believe  it  un- 
exampled in  the  human  species.  Thus,  then,  we  have  here,  side  by 
side,  each  extreme,  and  understanding  each,  there  is  not  likely  to 
come  anything  between  that  we  may  not  be  able  readily  to  explain. 

A  dental  germ  assuming,  or  compelled  to  an  abnormal  position, 
may  have  various  sequelae.  It  may  make  a  maleruption  ;  it  may  re- 
main encysted  ;  it  may  die  after  partial  development,  or  it  may  hetero- 
geneously  develop. 

We  have  then  but  to  consider  heterogeneous  development,  and  we 
have  mastered  the  pathology  of  the  lesion,  and  all  its  various  phases. 

First,  let  us  dissect  a  tooth — for  the  parts  of  a  tooth  are  the  parts 
of  such  tumors.  A  tooth  is  made  up  of  enamel,  dentine,  cementum, 
pulp  substance,  and  peridonteum. 

Enamel  of  the  Teeth. —  Cortex  strata,  adamantina  dentium; 
crusta  dentium  adamantina  ;  substantia  vitrea. 

The  enamel  of  a  tooth  is  that  portion  which  caps  the  crown.  In 
structure  it  is  fibrous ;  its  fibers  radiating  from  the  center  to  the 
surface. 

In  microscopic  structures,  the  enamel  (Owen)  consists  of  long 
and  slender,  solid,  prismatic,  for  the  most  part  hexagonal,  fibers  of 
phosphate,  carbonate,  and  fluate  of  lime  ;  which  are  essentially  the 
contents  of  extremely  delicate  membranous  tubes. 

Dentine. — Os  dentis,  substantia  ossea  ebur  dentis.  This  is  the 
portion  of  the  tooth  between  the  cementum  and  enamel  and  between 
the  pulp  and  the  enamel.  It  makes  up  the  great  body  of  the  organ. 
Dentine  is  composed  of  numberless  tubules,  these  being  not  larger 
than  the  one  ten-thousandth  of  an  inch  in  diameter ;  their  course  is 
waving,  each  tubule  having  several  curves  resembling,  according  to 
Retzius,  the  Greek  letter '?.  "  Professor  Retzius  confirms  the  observa- 
tion of  Miiller,  that  the  tubes  contain  an  organic  earthy  matter  in 
granular  masses,  which  disappear  under  the  action  of  dilute  muriatic 
acid.  The  cells,  and  the  small  tubes  which  radiate  from  them,  also 
contain  earthy  matter,  as  in  bone.  They  are  naturally  white  and 
opaque ;  but,  after  maceration  in  dilute  muriatic  acid,  become  color- 
less and  transparent." 

Chemically,  dentine  differs  from  enamel  principally  in  the  absence 
of  the  fluate  of  lime. 

Cementum — Crusta  Petrosa. — The  cementum  of  a  tooth  is  that 


344  ORAL  DISEASES  AND   SURGERY. 

portion  which  invests  the  fangs.  In  character,  it  corresponds  quite 
closely  to  the  osseous  structures.  The  microscope  demonstrates 
clearly  the  existence  of  Haversian  canals,  and  the  so-called  corpuscle 
of  Purkinje,  or,  as  Robin  prefers  to  term  them,  osteoplasts. 

"  In  growing  teeth,  with  fangs  not  fully  formed,  the  cement  is  so 
thin  that  the  Purkinjean  cells  are  not  visible ;  it  looks  like  a  fine 
membrane,  and  has  been  described  as  the  periosteum  of  the  fangs, 
but  it  increases  in  thickness  with  the  age  of  the  tooth,  and  is  the 
seat  and  origin  of  what  are  called  exostoses  of  the  fangs,  which  are 
wholly  composed  of  it."  "  It  is  the  presence  of  this  osseous  sub- 
stance," says  Professor  Owen,  "  which  renders  possible  many  well- 
known  experiments  of  which  the  human  teeth  have  been  the  subject; 
such  as  their  transplantation,  and  adhesion  into  the  combs  of  cocks, 
and  the  establishment  of  a  vascular  connection  between  the  tooth  and 
the  comb,"  etc.  Under  every  modification,  the  cement  is  the  most 
highly  organized,  and  most  vascular  of  the  dental  tissues,  and  its 
chief  use  is  to  form  the  band  of  vital  union  between  the  denser  con- 
stituents of  the  tooth,  and  the  bone  in  which  the  tooth  is  implanted. 

Dental  Pulp. — The  pulp  is  that  vascular,  reddish-gray,  highly- 
sensitive  substance,  occupying  the  cavity  of  the  tooth.  It  is  made 
up  of  delicate  connective  tissue,  in  which  ramify  the  dental  nerve, 
artery,  and  vein. 

"  When,"  says  Mr.  Nasmyth,  "the  internal  structures  of  a  dental 
pulp  are  examined,  the  number  of  minute  cells  which  present  them- 
selves in  a  vascular  form  is  remarkable ;  they  seem,  indeed,  to  con- 
stitute the  principal  portion  of  its  bulk."  Mr.  N.  describes  them  as 
"  varying  in  sizi?,  from  the  smallest  microscopic  appearance  to  one- 
eighth  of  an  inch  in  diameter ;  and  as  being  disposed  in  different 
layers  throughout  the  body  of  the  pulp."  This  tissue  is  highly  en- 
dowed, and,  perhaps,  more  liable  than  any  portion  of  the  body  to 
take  on  morbid  action ;  fungoid  degeneration  is,  perhaps,  its  second 
most  common  disease. 

Periodontal  Membrane. — This  is  the  periosteum  of  the  tooth. 
Anatomically  and  physiologically  it  differs  little  from  this  general 
class  of  membranes.  Pathologically,  I  think  it  may  be  remarked  as 
being  more  susceptible  to  disease,  and  more  disposed  to  assume 
quickly  the  acute  conditions.  For  example,  inflammation  of  the 
periodontal  membrane  is  easily  provoked,  and,  once  inflamed,  it  is 
ever  after  surprisingly  prone  to  reassume  morbid  action.  Again, 
we  need  only  call  to  mind  its  epulic  outgrowths ;  the  frequency  and 
varied  character  of  these  growths. 


TUMORS   OF   THE  MOUTH.  345 

Familiar  with  tooth  structure,  we  turn  to  Fig.  70,  as  referred  to, 
and  trace  a  perversion  of  development  in  all  these  structures  ;  see 
them  forming  a  tumor,  strictly  dental,  yet  to  the  last  degree  anoma- 
lous and  abnormal. 

We  return  now  to  the  microscopic  examination  of  tumor,  made  by 
Professor  Ch.  Robin.  Fig.  70  (400  diameters).  This  figure  repre- 
sents a  portion  of  a  slight  cut  made  into  the  tumor  represented 
(Fig.  69,  a). 

The  preparation  is  taken  from  near  the  free  edge,  or  the  irregu- 
larly mammillated  surface  of  the  tumor.  The  latter  is  formed 
principally  of  the  ivory  or  dentine,  easily  recognized  upon  the  thin 
section  by  its  very  fine  tubes,  disposed  in  parallels,  or  nearly  so, 
through  part  of  their  extent  (Fig.  70,  e). 

These  tubes,  radiating  more  or  less  regularly  from  the  little  de- 
pressions or  cavities  observable  in  the  mass  of  the  tumor  (Fig. 
69,  a),  very  near  to  each  other  through  part  of  their  extent,  these 
tiibes  of  ivory  become  more  rare,  fine,  and  ramified  as  they  approach 
the  surfaces  of  the  dental  tumor  (Fig.  70,  d,f),  and  end  in  a  very 
sharp  point  toward  the  lines  of  junction  between  the  ivory  and  the 
enamel  (a,  b,  c),  and  the  cement  (/,  g,  h).  The  presence  of  the  ivory, 
which  forms  the  greater  part  of  the  tumor,  demonstrates  its  dental 
nature  very  clearly. 

Enamel. — Another  important  particular  is  the  presence  of  the 
enamel  on  the  surface  of  the  tumor,  where  it,  in  some  measure, 
covers  the  irregularities  with  a  varnish  which  moulds  itself  upon 
them  in  order  to  penetrate  more  or  less  deeply  into  the  fissures  or 
depressions  that  divide  the  tumor  superficially  into  lobes. 

This  bed  of  enamel  varies  in  thickness  from  microscopic  dimen- 
sions to  a  millimeter  (-03937  inch),  or  near  it,  and  is  as  irregular  in 
places  on  the  lower  or  adhering  face  as  it  is  on  the  free  surface, 
which  the  microscope  alone  allows  to  be  seen.  The  portion  of  the 
section  of  the  tumor  that  is  here  delineated  (Fig.  70)  is  taken  at  the 
level  of  one  of  the  points  where  the  enamel  (a,  b)  in  a  manner  pene- 
trates (c)  into  the  body  of  the  ivory  mass  of  which  the  tumor  is 
principally  formed. 

The  enamel  is  easily  recognized  by  its  narrow  prisms,  from  six  to 
eight-thousandth  of  a  millimeter  in  width,  which  are  in  immediate 
juxtaposition  (Fig.  70,  a,  b).  The  figure  shows  them  inclined,  as  by 
the  accidents  of  the  cuts  in  making  the  section.  When  the  cut  is 
perpendicular,  or  nearly  so,  to  their  greatest  axis,  their  prismatic 
form,  with  five  or  six  faces,  is  easily  seen ;  this  is  shown  in  the 
neighborhood  of  6,  Fig.  70. 


346  ORAL  DISEASES  AND  SURGERY. 

Cement. In  the  depth  of  the  fissures,  and  here  and  there  in  the 

mass  of  the  tumor,  near  its  surface,  and  especially  that  part  of  the 
surface  hidden  in  the  adventitious  cavity  of  the  maxillary  bone,  the 
microscope  discovers  some  trails  or  beds  of  variable  thinness,  formed 
entirely  of  the  substance  of  the  cement  (Fig.  70,  g). 

The  cement  is  inclosed  between  masses  of  ivory,  and  is  consoli- 
dated by  the  immediate  contact  (Fig.  70)  with  the  masses  between 
which  it  lies.  It  extends  itself  in  places  with  the  surface  of  the 
tumor  to  the  neighborhood,  and  even  to  contact  with  the  enamel. 
The  section  represented  in  the  plate  is  taken  at  a  point  that  shows 
this  arrangement  (Fig.  TO,/,  g,  h).  There  are,  besides,  thin  pieces 
of  cement  extending  far  forward  into  the  body  of  the  tumor. 

The  cement  is  known  to  be  no  other  than  the  osseous  substance. 
The  figure  before  us  exhibits  the  characteristic  elements  belonging 
to  it.  These  are  the  microscopic  cavities,  called  osteoplasts,  or,  in- 
correctly, osseous  corpuscles,  for  they  are  excavations.  The  air 
that  fills  the  dry  bone  makes  these  cavities  appear  black  under  the 
microscope  (Fig.  70,  g)\  but,  in  the  fresh  state,  they  are  full  of 
liquid,  and  are  pale  and  more  difficult  to  observe  than  in  the  dry 
pieces. 

These  cavities,  which  are,  in  breadth  and  length,  from  one  to 
three-hundredths  of  a  millimeter,  are  always  of  very  irregular  shape, 
on  account  of  the  presence  of  the  fine  tubes  that  start  from  all  their 
peripheries,  and  traverse  even  the  substance  interposed  between  the 
osteoplasts. 

The  best  joined  pieces  show  that  these  little  canals  are  subdivided 
two  or  three  times,  and  are  then  inosculated  with  those  of  neighbor- 
ing osteoplasts.  The  portion  of  cement,  shown  in  the  plate,  does 
not  exhibit  this  arrangement,  which  was  visible,  nevertheless,  in  the 
parts  close  to  it. 

The  cuts  in  the  tumor  exhibit,  moreover,  little  openings,  that  are 
either  full  or  empty,  of  a  grayish  or  brown  pus.  These  small  orifices 
are  from  two  to  six-tenths  millimeter  and  upwards  in  width,  and 
from  about  one  to  two  millimeters  apart.  The  microscope  shows 
that  these  orifices  accompany  the  narrow,  irregular  cavities,  some- 
times in  the  form  of  elongated  conduits,  hollowed  out  of  the  ivory 
which  they  pass  through.  The  instrument  also  shows  that  the 
tubes  of  the  latter  start  from  these  cavities  to  radiate  toward  the 
surface  of  the  tumor,  in  the  same  manner  as  the  tubes  of  the  ivory 
in  the  normal  tooth  start  from  the  natural  cavity  of  the  dental  pulp. 
These  narrow,  irregular  cavities,  more  or  less  elongated,  traverse  the 


TUMORS   OF   THE  MOUTH.  347 

mass  of  the  tumor,  and  some  of  them  even  reach  within  a  few  milli- 
meters of  the  surface. 

These  cavities  are,  in  reality,  nothing  more  than  the  pulp  cavities 
of  this  morbid  product,  either  rugous  from  desiccation  or  still  con- 
taining some  remnant  of  the  dried  pulp  in  the  form  of  a  brownish  or 
grayish  powder. 

Recapitulation. — The  result  of  all  these  observations  of  the  case 
is  thus  epitomized  by  M.  Forget. 

1st.  An  original  union  of  the  follicles  of  the  last  two  molars  fol- 
lowed by  an  intimate  union  of  them,  caused  by  phlegmasial  or  other 
actions. 

2d.  Under  the  same  morbid  influence,  the  excess  of  vitality  in  the 
organic  elements  of  the  follicles  has  produced  hypersecretion  of  an 
ivory-like  osseous  substance. 

3d.  That  the  irregular  aggregatism  and  diffusion  of  these  consti- 
tutes the  pathological  growth. 

4th  and  lastly.  Its  growth  has  formed  in  the  cyst,  and  it  has  main- 
tained therein  a  permanent  inflammation  which  has  disorganized  the 
osseous  tissue  and  altered  the  structure  of  the  adjacent  soft  parts  to 
such  an  extent  that  a  radical  operation  was  necessary. 

Thus  we  have  studied  the  extremes:  a  simple  cyst,  with  a  tooth 
in  it,  and  a  tumor  so  complex  in  character  and  structure  that  no  one 
but  the  microscopist  might  hope  to  be  able  to  recognize  it.  Yet 
these  tumors,  differing  so  widely  in  their  features,  are  alike  in  the 
most  important  one  of  being  benign.  Their  prophylaxis  is  the  same, 
and  for  a  good  distance  their  surgery  runs  side  by  side. 

Dental  tumors,  intermediate  to  these  two  classes,  are  of  various 
features.  But,  with  an  ability  to  recognize  the  dental  elements — 
with  an  understanding  of  the  minute  histology  of  enamel,  dentine, 
cementum,  and  pulp  substance — what  difference  can  it  make,  having 
eyes  and  a  microscope,  how  these  elements  aggregate  ? 

I  once  saw  a  tumor  taken  from  the  maxilla,  which  looked  like  a 
mass  of  ivory ;  it  was  quite  as  large  as  two  of  the  molar  teeth  put 
together.  I  need  scarcely  say  that  it  was  two  of  the  molars ;  their 
germs  had  in  some  way  affiliated,  and,  remaining  encysted,  had  pro- 
duced this  abortion.  The  microscope  revealed  very  distinctly  the 
tubulated  character  of  the  mass;  this  pronounced  it  dental  quite  as 
satisfactorily  as  though  the  shapeless  lump  had  been  moulded  to  the 
tooth-form. 

I  have  had  shown  me,  as  great  curiosities,  teeth  with  ivory  masses 


348  ORAL  DISEASES  AND   SURGERY. 

projecting  at  right  angles  from  their  crowns.  I  never,  however, 
have  seen  this  anomaly  where  it  was  not  plainly  evident  that  the 
projection  was  a  twin  tooth— the  result  of  germ  union ; — there 
would  be  a  tooth  missing  in  the  arch. 

Manv  curious  illustrative  instances  could  be  mentioned  of  anoma- 
lous incongruities  in  dental  evolution ;  but,  as  we  are  prepared  to 
understand,  we  would  find  them  in  character  the  same — enamel, 
dentine,  ccmentum,  and  pulp  structure.  The  arrangement  only 
would  be  found  to  differ;  with  our  eyes,  or  assisted  by  the  micro- 
scope, we  could  or  should  be  able  to  say  of  any  of  them.  This,  and 
this,  and  this  is  dental. 

The  ability,  then,  to  distinguish  a  dental  from  a  malignant  osteoid 
tumor,  must  certainly  prove  a  source  of  much  satisfaction;  for,  as  M. 
Forget  curtly  remarks,  if  intervention  cannot  be  too  radical  in  an 
instance  of  cancer,  it  is  certain,  on  the  contrary,  that  more  caution 
and  moderation  are  necessary  when  it  is  a  question  of  a  lesion, 
which  is  essentially  local  and  of  a  benignant  nature,  and  allows  the 
surgical  operation  to  be  restricted  to  the  precise  limits  of  the  lesion, 
without  its  being  necessary  to  provide  against  an  improbable  repe- 
tition by  encroaching  upon  the  osseous  tissues  that  border  on  it,  and 
thus  su1)jecting  the  patient  to  a  mutilation  which  could  not  be  justified. 

Data. — 1.  There  are  twenty  teeth  in  the  deciduous  denture, 
which  twenty  are  to  be  replaced  by  thirty-two,  each  of  which  is  to 
be  at  least  twice  the  size  of  its  predecessor. 

2.  A  contracted  maxilla,  having  no  accommodation  for  certain 
teeth,  the  germs  of  which  are  in  the  jaw,  gives  us,  among  other 
lesions,  irregularity  in  dental  evolution. 

3.  Irregularity  in  evolution  yields  morbid  conditions,  as  described, 
and  which  conditions  are  influenced,  not  unlikely,  by  peculiarities  of 
the  general  organization  and  manner  of  interference  with  develop- 
ment. 

4.  An  overcrowded  arch  will  surely  yield  periodontal  and  other 
minor  troubles,  and  may  produce  lesions  of  grave  character.  The 
extraction  of  certain  of  the  bicuspidate  teeth  of  the  permanent  set 
should,  therefore,  be  practiced,  whenever  time  shall  make  evident 
the  existence  of  contraction  on  the  part  of  the  arch. 

5.  Dental  tumors  vary  from  simple  cystic  growth  to  such  perverse 
and  anomalous  evolutions,  that  the  microscope  only  is  capable  of 
explaining  them. 

fi.  A  dental  tumor  is  an  abnormal  growth,  having  its  point  of  de- 
parture and  development  in  irregularity  of  dental  evolution. 


TUMORS   OF   THE  MOUTH.  349 

7.  Dental  tumors  are  benign;  operations  for  their  cure  promise  all 
success,  and  may  be  practiced  in  exclusive  consideration  of  the  dis- 
ease as  it  locally  exists. 

8.  The  existence  of  a  dental  tumor  is  to  be  inferred,  caeteris  pari- 
bus, when  there  is  deficiency  and  derangement  in  the  dental  arch. 

CYSTIFORM  ANTRA. 

Fig.  71  represents  a  cystic  tumor,  or,  rather,  expansion  of  the 
walls  of  the  antrum,  as  occasionally  met  with.  The  cyst  repre- 
sented in  the  view  occurred  in  the  person  of  a  young  gentleman 
some  twenty  years  of  age,  from  whose  jaw  I  removed  it  two  years 

Fig.  71. — Antral  Cyst. 


back.  This  cyst,  the  size  of  an  ordinary  orange,  was  successfully 
treated  without  external  incision,  the  soft  parts  being  dissected 
off  by  pulling  outward  and  upward  the  angle  of  the  mouth ;  the 
wall  of  the  cyst,  about  the  thickness  of  ordinary  parchment,  was  cut 
away  with  a  chisel.  This  particular  cyst  was  without  contents  of 
any  kind.  After  the  removal  of  the  vault  the  soft  parts  were  per- 
mitted to  fall  into  the  cavity  of  the  sinus;  no  deformity  at  all  re- 
sulted, and  no  trouble  has  since  been  experienced. 

An  interesting  feature  in  this  character  of  cases  is  found  in  the 
tenacity  on  the  part  of  the  antrum,  after  operation,  to  maintain  its 
cavity.  I  have  tried  my  best  to  obliterate  this  sinus  by  compel- 
ling granular  activity  in  its  mucous  membrane,  but  so  long  as  I  have 
been  enabled  to  watch  my  cases,  and  in  one  that  I  recall,  seven  months 
elapsed  before  the  overlying  tissues  so  covered  in  the  part  as  to  con- 
ceal it  from  observation  ;  in  none  of  them  have  I  been  able  to  satisfy 


350  ORAL  DISEASES  AND   SURGERY. 

myself  as  to  what  was  the  subsequent  condition  of  the  sinus ;  my 
impression  is,  however,  that  the  mucous  membrane  maintains  itself, 
and  that  a  species  of  cavity  continues  to  exist. 

Hydrops  antri  is  another  form  of  cystiform  enlargement  of  this 
cavity.  The  dilatation  in  these  cases  is  gradual  and  painless,  and 
when  the  bone  becomes  expanded  to  any  considerable  extent,  fluctu- 
ation is  commonly  apparent,  the  vault  of  the  cyst  yielding  readily 
enough  to  pressure.  If  any  obscurity  exists,  it  may  be  removed  by 
the  use  of  the  exploring  needle.  It  sometimes  happens,  in  these 
cases,  that  the  floor  of  the  orbit  becomes  the  yielding  point,  or  it 
may  be  the  canine  fossa,  the  tuberosity,  or  the  hard  palate  ;  the  lat- 
ter boundary,  however,  according  to  my  observation,  is  the  most  fre- 
quent seat  of  the  enlargement  forming  the  tumor  within  the  mouth. 

Hydrops  antri  depends,  in  many  cases,  on  the  formation  of  a 
cyst  within  the  cavity.  In  others  it  may  be  viewed  as  a  simple 
mucous  engorgement,  the  natural  outlet  into  the  meatus  being, 
from  some  cause  or  other,  obliterated.  A  very  expressive  illustra- 
tion of  the  first  of  these  conditions  was  exhibited  in  a  specimen 
taken  by  myself  some  three  years  back  from  the  antrum  of  a 
young  man.  In  this  case  the  cyst  seemed  to  spring  from  the 
root  of  the  second  molar  tooth,  or  its  immediate  neighborhood  ;  the 
mucous  membrane  had  been  dissected  up,  and  covered  the  cyst  as  a 
reflex  tunic.  Although  this  particular  tumor  was  not  large  enough 
to  exhibit  external  evidence  of  its  existence,  yet  there  are  no  reasons 
for  inferring  that  such  tumefaction  would  not  eventually  have  re- 
sulted. A  case  of  interest,  in  this  direction,  is  recorded  in  the  prac- 
tice of  Dr.  Chase,  of  Iowa  City,  who  reports  it  in  the  Dental  Cosmos, 
accompanied  with  diagram. 

Description  of  Case. — "An  Irishwoman,  aged  forty  years,  came 
to  have  the  right  first  upper  molar  extracted.  I  found  her  teeth  in 
a  bad  condition  generally :  they  were  decayed  and  loose,  and  the 
gums  congested.  This  particular  tooth  was  decayed  and  very  loose. 
On  pressing  it,  the  alveolus  seemed  to  move  with  the  tooth.  Ad- 
joining it  in  front,  was  the  root  of  the  second  bicuspid — the  crown 
gone. 

"  As  she  was  of  that  class  who  make  no  attempt  to  preserve  their 
teeth,  I  extracted  the  molar  without  hesitation.  She  had  told  me 
that  her  'jaw'  had  ached  for  three  or  four  months  previous  to  this 
time.  On  applying  the  forceps,  the  beaks  readily  passed  under  the 
gums  without  lancing,  and  the  tooth,  much  to  my  surprise,  came 
away  with  a  very  slight  application  of  force.    But  this  surprise  was 


TUMORS   OF  THE  MOUTH.  351 

not  equal  to  my  astonishment,  when  I  saw  what  I  had  brought 
away  with  the  tooth,  namely,  a  large  quantity  of  alveolar  substance, 

Fig.  72. — Secondary  Cyst  of  the  Antrum. 


6 

1,  root  of  second  bicuspid  attached  to  alveolus  ;  2,  neck  of  tooth  and  border  of  alveolus  ; 
3,  walls  of  antrum,  palatal  side ;  4,  center  of  crown  of  tooth ;  5,  tumor  ;  6,  tartar,  cover- 
ing the  cavity  of  decay.  The  buccal  aspect  of  the  tooth  was  similar  in  appearance  to  the 
palatal  surface  which  is  seen  in  the  engraving. 

the  bicuspid  root,  and  a  fibrous  connective  tissue  tumor,  nearly  an 
inch  in  diameter,  attached  to  the  tooth,  and  inclosing  two  of  the 
roots,  namely,  the  posterior  buccal,  and  the  palatine  roots. 

"After  being  in  alcohol  three  days,*  the  tumor  was  nearly  white, 
and  had  shrunken  to  one-third  its  original  size.  On  cutting  it  open, 
it  was  found  filled  with  a  solid  structure.  The  consistence  was  that 
of  tubercle,  or  pressed  cheese-curd  ;  the  color,  light  yellow,  tinged  in 
most  parts  with  red. 

"  The  roots  within  the  tumor  were  nearly  free,  and  covered  with 
their  periosteum,  which  had  thickened  into  a  loose,  spongy  mass, 
extending  even  to  the  base  of  the  body  of  the  tooth.  The  appear- 
ance was  like  that  of  roots  involved  in  alveolar  abscess.  The  walls 
of  the  tumor  were  not  composed  of  detached  dental  periosteum. 
There  were  apparently  two  coats,  the  outer,  fibrous,  like  periosteum ; 
the  inner,  a  mucous  one,  like  the  lining  of  the  nasal  cavity." 

The  pathology  of  the  case,  as  inferred  by  Dr.  Chase,  is,  that  the 
tooth  decayed  to  the  pulp  cavity,  that  the  pulp,  after  repeated  in- 
flammatory attacks,  died.  Putrefaction  of  that  organ  occurred,  pro- 
voking periodontitis ;  after  awhile  suppuration  occurred,  and  the 
disease  became  chronic.  The  periodonteum  became  thickened  and 
spongy,  continued  irritation  caused  a  proliferation  of  connective 

*  It  is  to  be  regretted  that  an  examination  had  not  been  made  at  once. 


352  ORAL  DISEASES  AND   SURGERY. 

tissue  corpuscles,  thus  eventuating,  finally,  in  the  formation  of  the 
cyst. 

This  inference  is,  I  think,  the  true  explanation  of  the  cyst ;  the 
trouble,  however,  was  seated  primarily  on  the  bicuspid  and  not  the 
molar  roots — involving  the  latter  secondarily.  This  tumor,  although 
it  possessed  not  the  contents  of  the  one  operated  on  by  myself,  yet 
has  a  similar  pathological  signification :  it  constitutes  a  most  in- 
structive study. 

In  cases  of  this  kind  it  will  be  seen  at  a  glance  that,  however 
patulous  the  natural  outlet  might  be,  the  contents  of  the  tumor  could 
not  by  such  means  find  egress.  In  the  second  character  of  cases, 
the  contents  are  just  within  the  cavity,  but  the  engorgement  of  the 
tissue  bounding  the  outlet  has  closed  the  foramen.  A  case  described 
in  the  chapter  on  Diseases  of  the  Antrum  exhibits  the  dangerous  and 
destructive  efifects  of  such  accumulations  when  unappreciated  and 
untreated. 


CHAPTER    XXIII. 

EXOSTOSIS   AND    SUBACUTE   INFLAMMATORY   TUMORS. 

The  term  exostosis,  as  the  reader  will  recall,  is  derived  from  the 
expressive  roots  ef ,  out  of,  and  (xrrsov,  a  bone ;  an  osseous  tumor 
which  forms  at  the  surface  of  bones,  or  in  their  cavities ;  the  first  is 
called  exostosis,  the  latter  enostosis. 

The  following  varieties  have  been  named:  "ivory  exostosis,  that 
which  is  ivory-like ;"  lamina  exostosis,  that  which  is  made  up  of  dis- 
tinct fibers  or  layers  ;  spongy  exostosis,  that  which  is  like  the  spongy 
tissue  of  bone. 

Hyperostosis  is  precisely  the  same  thing  as  exostosis,  both  being 
inflammatory  hypertrophies.  Inflammatory  osseous  tumors  are 
hyperostoses. 

Because,  however,  there  are  great  differences  in  the  expression  of 
these  conditions,  I  shall  write  of  them  under  special  heads. 

Exostosis,  as  commonly  met  with  in  the  mouth,  is  strictly  benign. 
It  is  generally  recognizable  by  its  extreme  slowness  of  growth,  the 
entire  absence  of  pain, — except  when  it  meets  with  some  peculiar  ob- 
struction,— and  its  freedom  from  surrounding  disease.  It  does  not 
tend  markedly  to  ulceration,  and  does  not,  except  mechanically, 
affect  the  parts  even  most  directly  associated  with  it. 

True  exostosis  has  its  origin  in  local  irritations,  perhaps  always. 
It  is  true  that  reference  is  made  by  authors  to  an  ossific  diathesis, 
but,  as  truly  remarked  by  Miller,  "A  skeleton  so  susceptible  is  prone 
rather  to  the  more  common  inflammatory  products  of  caries,  ab- 
scesses, ulcers,  and  necrosis." 

That  local  irritation  is  the  chief  cause  of  exostosis  is  satisfac- 
torily proven,  I  think,  by  reference  to  parts  most  subject  to  this 
interference.  The  teeth,  for  example,  are  found  exostosed  in  a  thou- 
sand instances  to  one  of  any  other  bone,  and  certainly  no  bones  are 
so  constantly  found  in  irritative  conditions.  I  use  the  term  "bone," 
reminding  the  reader  that  the  portion  of  the  tooth  which  takes  on 
this  morbid  action  is  almost,  in  every  proper  sense,  true  bone. 

Non-specific  exostosis,  occurring  on  any  portion  of  the  maxillary 

23  ( 353  ) 


354  OEAL  DISEASES  AND  SURGERY. 

bones  removed  from  the  alveolar  borders,  is  an  exceedingly  infre- 
quent affection.  With  every  opportunity  for  observation,  I  am  sur- 
prised  at  the  fewness  of  the  cases  I  recall  ever  to  have  seen ;  and 
most  of  these  have  been  small,  and  of  little  consequence. 

Around  the  base  of  the  alveolar  processes,  however,  and  particu- 
larly on  the  lingual  aspect  of  the  lower  jaw,  this  affection,  in  a  minor 
form,  is  exceedingly  common ;  certainly  I  have  seen  hundreds  of 
examples,  the  enlargements  varying  from  the  size  of  a  small  shot  to 
that  of  a  rifle-ball !  As  pathological  relations  are  concerned,  how- 
ever, they  seem  of  little  consequence  ;  I  never  knew  one  to  result  in 
any  harm ;  the  treatment  I  have  adopted  in  such  cases  has  been  the 
very  simple  one  of  letting  them  alone. 

It  is  not  improbable  though  that  cases  may  present  when  opera- 
tions seem  demanded.  I  have  felt  called  to  operate  upon  some  two  or 
three  of  such  as  I  have  met  with.  The  mode  of  procedure  is  simply 
to  lay  off  from  the  tumor  the  soft  parts,  and,  with  a  chisel,  cut  away 
the  mass  ;  there  is  no  hemorrhage  or  other  trouble  attendant  on  the 
operation.  (See  nyperoHtosia.) 

Exostosis  of  the  fangs  of  the  teeth — exostosis  dentium — the  usual 
seat  of  the  disease  in  the  maxillary  regions,  finds  location  both  in 
the  cemental  and  dentinal  structures  of  these  organs ;  for  while  I 
have  seen  two  or  three  cases  where  the  crowns  of  the  teeth  were 
enlarged,  as  if  from  a  species  of  exostosis  or  hypertrophy,  yet  these 
were  so  anomalous  that  I  may  describe  the  growth  as  being  associ- 
ated exclusively  with  the  fangs ;  and  even  here,  I  think,  it  will  be 
found  in  the  majority  of  instances  confined  mostly  to  the  apex, 
growing,  bulblike,  as  it  were,  about  the  end  of  the  root. 

The  diagnosis  of  exostosis  in  these  situations  is  not  by  any  means 
easy.  The  most  frequent  pathognomonic  feature,  however,  is  a 
sense  of  continued  uneasiness  about  the  parts,  not  generally  amount 
ing  to  pain,  but  serving  as  a  constant  reminder  of  the  presence  of 
the  tooth.  The  tooth  itself  may  or  may  not  be  carious.  Pressure, 
or  the  stroke  of  an  instrument,  does  not,  in  ordinary  cases,  either  in- 
crease or  diminish  the  soreness ;  the  sense  of  fullness  about  the 
parts  is  particularly  observed  where  the  absorption  of  the  alveolus  is 
not  proportionably  active  with  the  exostosis.  In  these  latter  cases, 
the  extremest  symptoms  of  neuralgia  are  not  unfrequently  produced, 
and  which,  not  comprehended,  are  of  course  treated  without  avail. 

One  of  the  most  remarkable  cases  of  dental  exostosis  on  record  is 
related  by  Mr.  Fox.  The  subject  was  a  young  lady,  who,  at  the 
time  she  sought  the  professional  aid  and  advice  of  Mr.  Fox,  had  suf- 


EXOSTOSIS,  ETC.  355 

fered  so  severely  and  so  long  that  the  palpebrse  of  one  eye  had  been 
closed  for  nearly  two  months,  and  the  secretion  of  saliva  had  for 
some  time  been  so  copious  that  it  flowed  from  her  mouth  whenever 
it  was  opened.  She  had  tried  every  remedy  which  had  been  recom- 
mended by  the  ablest  professional  advisers,  without  realizing  any 
permanent  benefit,  and  was  only  relieved  by  the  extraction  of  every 
one  of  her  teeth. 

The  practitioner  may  infer  from  the  mention  of  this  case  that  he 
is  likely  to  meet  with  many  gradations  of  the  trouble.  The  cure 
will  consist  in  the  removal  of  the  affected  member :  this,  after  the 
diagnosis,  is  always  easily  accomplished  with  the  aid  of  a  pair  of 
cutting-forceps. 

In  the  venereal,  scorbutic,  and  tubercular  hypertrophy  or  exosto- 
ses of  the  maxillary  bones,  the  features  of  the  common  disease  be- 
come quickly  evident  in  the  local  trouble,  so  remarkably  so,  in- 
deed, that  no  one  would  be  at  all  likely  to  misunderstand  things, 
presupposing  the  general  disease  be  understood.  The  growths  are 
rapid,  painful,  and  always  more  or  less  amenable  to  constitutional 
treatment. 

Scrofulous  and  scorbutic  tumors  differ  from  the  venereal  in  being 
more  loose  and  spongy  in  structure,  and,  in  consequence,  more  apt 
to  run  into  abscess,  being  possessed,  as  it  were,  of  elements  for  their 
own  destruction. 

In  these  forms  of  maxillary  disease,  the  lesion  is  commonly 
heralded  by  deep-seated,  dull  pains,  which  precede  by  some  time 
the  visible  enlargement  of  the  pai't.  After  the  tumefactive  process 
once  sets  in,  it  goes  on,  if  uncombated,  until  the  parietes  of  the  bone 
are  completely  disparted.  Associated  with  this  enlargement  is  an 
unhealthy  condition  of  the  soft  parts. 

As  the  disease  advances,  the  center  of  the  tumor  softens,  while 
the  character  of  the  pain  changes,  becoming  sharp  and  throbbing ; 
as  pus  forms,  sinuses  are  created,  and  thus  ulcerations  occur  on  the 
face  of  the  tumor. 

The  treatment  of  inflammatory  tumors  of  these  and  similar  types 
is  to  be  conducted  in  consideration  of  their  twofold  requirements. 
The  systemic  influences  are  to  be  corrected,  while  locally,  I  think  I 
am  justified  in  asserting  that,  as  a  rule,  they  will  succumb  to  the 
treatment  commonly  directed  against  similar  abscesses  of  the  soft 
parts.  I  have  great  confidence  in  the  use  of  tents  and  stimulating 
injections. 

There  is  a  simple  inflammatory  tumefaction  of  the  maxilla  some- 


356  ORAL  DISEASES  AND  SURGERY. 

times  met  with,  which  might  be  mistaken  for  specific  exostosis. 
It  is  to  be  distinguished,  however,  by  the  greater  rapidity  of  the 
swelling  and  by  the  greater  soreness  attendant  on  it;  it  comes, 
as  a  cold  in  the  head,  or  on  the  chest, — comes  without,  in  the  ma- 
jority of  cases,  the  patient  being  able  to  assign  any  cause,  and  it  is 
found  soon  to  give  way  to  the  same  class  of  antiphlogistics.  This 
tumefaction  is  extra  rather  than  intramaxillary ;  it  is,  more  than 
likely,  a  periosteal  exudate ;  it  has,  of  course,  no  constitutional  asso- 
ciative lesion. 

In  this  connection,  attention  may  be  directed  to  a  form  of  tumor 
frequently  found  in  the  mouth,  and  which,  I  think,  is  pathologically 
classible  with  the  exostoses.  I  allude  to  an  apparent  expansion 
of  bone  frequently  found  in  association  with  a  strumous  diathesis, 
and  so  invariably  in  connection  with  periosteally  diseased  teeth  or 
roots  of  teeth  ;  not  always,  however,  are  these  expansions  or  growths 
in  association  with  the  strumous  condition,  as  I  have  often  enough 
treated  them  in  individuals  whose  constitutional  conditions  seemed 
perfect. 

These  tumors  have  a  common  history.  The  nerve  of  a  tooth  dies 
and  the  periosteum  takes  on  a  chronic  irritative  condition,  or  per- 
haps a  tooth  has  been  fractured  in  attempts  at  extraction,  and  the 
root,  or  some  portion,  has  been  left  in  the  socket.  After  a  time, 
sooner  or  later,  a  slight  swelling,  apparently  of  the  gum,  is  ob- 
served. This  may  readily  enough  be  taken  for  a  chronic  alveolar 
abscess;  there  is  no  pain,  however,  associated  with  the  enlarge- 
ment, which  is  soon  seen  to  differ  from  the  abscess  in  the  slow- 
ness of  its  evolution;  it  is  also  hard,  and  perfectly  unyielding  under 
pressure.  As  we  watch  the  case  month  after  month  we  find  it 
gradually  enlarging,  giving  to  the  observer  the  impression  of  an  ex- 
pansion of  the  bone  under  the  gums,  although,  as  we  understand, 
there  are  no  special  or  marked  signs  of  such  cystiform  condition.  If 
we  pass  an  exploring  needle  into  the  tumor,  it  feels  as  if  cutting  its 
way  through  spongy  bone;  and  so  indeed  it  does,  as  dissection 
will  reveal  to  us  that  the  cancellated  structure  has  taken  on  hyper- 
trophic action,  and  it  is  such  spongy  enlargement  that  bulges  out 
the  overlying  parts  and  makes  the  tumor.  1  have  treated  a  great 
number  of  these  growths,  and  invariably  in  connection  with  the  in- 
ferior jaw.  I  do  not  think  they  would  often  be  found  in  the  superior, 
such  chronic  conditions  being  here  more  apt  to  induce  caries,  which 
disease  we  know  to  be  as  uncommon  to  the  lower  as  it  is  common 
to  the  upper  jaw.     These  tumors,  so  far  as  I  have  seen,  have  no 


EXOSTOSIS,  ETC.  357 

tendency  to  take  on  malignant  action ;  they  either  remain  fixed  in 
character,  after  growing  to  the  size  of  a  half  walnut,  or,  in  very  bad 
subjects,  they  degenerate  into  abscess,  and,  discharging  the  offending 
body,  cure  themselves.  Such  spontaneous  cure  is,  however,  very 
rare. 

The  surgical  treatment  of  these  tumors  is  both  simple  and 
effectual.  It  is  enough,  not  unfrequently,  to  remove  the  tooth  or 
root,  particularly  if,  in  connection  with  such  removal,  we  keep  the 
socket  open  for  a  few  weeks  with  a  tent  of  cotton  or  sponge.  A  very 
certain  method,  and  one  which  I  am  in  the  habit  of  employing  in  my 
own  practice,  consists  in  cutting  away,  with  a  delicate  gouge,  the 
enlarged  mass :  this  is  easily  enough  accomplished  by  using  the 
opening  made  in  the  extraction  of  the  tooth  as  a  means  of  ingress  to 
the  mass ;  it  can  in  this  way  be  cut  out,  piece  by  piece,  without  any 
external  incision,  and  with  a  wound  not  larger  than  that  made  by 
the  preliminary  extraction.  After  such  operation  the  parts  are  to 
be  well  syringed  and  a  tent  kept  in  the  tooth-socket  to  insure  granu- 
lations from  the  circumference  of  the  wound.  In  two  or  three  weeks 
the  cure  will  commonly  be  found  complete. 

In  this  connection  I  may  call  attention  to  an  obscurity  which 
sometimes  seems  to  exist  in  the  diagnostic  relationship  of  diseased 
teeth, — that  is,  no  teeth  or  roots  of  teeth  may  seem  to  be  present. 
A  sufficiently  close  observation,  however,  will  always  detect  in  the 
neighborhood  a  fistulous  opening;  it  may  be  very  minute,  but  it  is 
seldom,  if  ever,  absent.  If  a  probe  be  passed  into  this  orifice  it  will 
lead  to  the  offending  agent. 

HYPEKOSTOSIS. 

In  connection  with  the  simple  tumors,  reference  may  now  be 
made  to  general  facial  hyperostosis  sometimes  existing.  In  a  work 
lately  published  by  Mr.  Heath,  being  the  Jacksonian  prize  essay  for 
1867  of  the  Royal  College  of  Surgeons,  England,  the  following 
illustrative  diagram  and  description  of  case  are  given  : 

The  patient,  when  about  forty-five  years  age,  and  apparently  in 
perfect  health,  was  exposed  to  a  cold  wind ;  immediately  after  which 
he  perceived  an  itching  and  heat  in  his  eyes,  and  swelling  of  the 
face  rapidly  supervened.  A  small  tumor  formed  just  below  the 
inner  angle  of  each  eye,  which  burst,  and  after  twelve  weeks  he  was 
able  to  resume  his  employment.  He  suffered  from  inflammatory 
attacks  in  the  tumors,  with  much  pain  in  the  head  on  more  than  one 
occasion,  and  consulted  many  medical  men ;  but  no  treatment  re- 


358 


ORAL  DISEASES  AND   SURGERY. 


lieved  the  disease  or  retarded  the  growth  of  the  tumors,  which  in- 
creased slowly,  and  were  of  stony  hardness.  The  eyes  were  pro- 
jected from  the  orbits  l)y  the  tumors,  and  the  right  eye  inflamed  and 
burst,  while  the  left  was  accidentally  ruptured  by  a  blow.  The  patient 


Fig.  73. — Hyperostosis. 


lived  to  over  sixty  years  of  age,  and  died  of  apoplexy,  having  been 
occasionally  maniacal  during  the  last  two  years  of  life.  The  por- 
trait is  taken  from  the  work  of  Mr.  Howship  (Practical  Observations 
on  Surgery).  The  skull  of  the  patient  is  preserved  in  the  College 
of  Surgeons,  and  shows,  as  might  be  anticipated  from  the  portrait, 
two  large  masses  of  almost  exactly  symmetrical  form  and  arrange- 
ment, which  have  partially  coalesced  in  the  median  line.  The 
growths  are  as  hard  as  ivory,  and  consist  of  very  close,  cane  llous 
structure.  They  project  more  than  three  inches  from  the  face  and 
an  inch  beyond  the  malar  bones  on  each  side.  The  man  attributed 
the  growths  to  repeated  blows  received  on  the  face  in  fighting. 

The  skull  of  a  Peruvian  (3093  College  of  Surgeons)  is  also 
alluded  to  by  Mr.  Heath.  In  this  case  the  disease  is  of  a  more 
diffused  character,  all  the  bones  of  the  face,  as  well  as  the  frontal 
and  the  adjacent  parts  of  the  sphenoid  and  parietal,  being  enlarged 
and  thickened  in  a  remarkable  manner.  The  nasal  fossae  and  orbits 
are  nearly  closed,  the  superior  maxillary  bones  having  grown  into 
great  knobbed  and  tubercular  masses,  in  which  their  original  form 
can  hardly  be  discovered.  The  hard  palate  is  similarly  diseased. 
The  lower  jaw  is  enormously  enlarged  at  its  right  angle,  and  in  the 
greater  part  of  its  right  half  it  measures  upwards  of  five  inches  in 
circumference,  and  all  but  three  of  its  alveoli  are  closed  up.     A 


EXOSTOSIS,  ETC.  359 

section  of  the  lower  jaw  shows  that  its  interior  is  composed  of  an 
almost  uniformly  hard  and  compact,  but  finely  porous,  bone.  There 
is  no  history  attached  to  the  specimen. 

Hyperostosis  is  simply  exostosis  or  enostosis.  It  is  analogous  to 
hypertrophy  of  the  soft  parts,  and  must  have  a  similar  history. 

As  can  be  very  well  understood,  varieties  in  form  and  character 
present  themselves.  These  growths  are  sometimes  associated  ex- 
clusively with  the  face  of  a  bone,  as  in  the  ordinary  exostosis.  In 
these  cases  the  periosteum  may  separate  the  two  bodies.  In  other 
cases  there  is  hypertrophy  of  the  bone  proper.  The  condition  is  one 
of  disease  only  as  there  is  a  lack  of  correspondence  in  other  parts. 
Any  section,  as  in  a  specimen  in  Dr.  Gross's  collection,  exhibits  the 
peculiar  features  of  bone  substance ;  it  may  be  that  the  cancellous 
substance  is  compressed  into  solidity,  but  there  is  the  deraarkation 
between  it  and  the  cortical  boundary,  and  the  analysis  remains  the 
same, — that  is,  as  the  constituent  parts  are  concerned.  When  these 
hypertrophies  associate  exclusively  with  the  endosteum,  as  in  the 
long  bones,  they  obliterate  or  diminish  the  medullary  canal,  and,  if 
of  sufficient  size,  expand  into  a  tumor,  greater  or  less  in  size,  the 
external  parts. 

The  history  of  any  form  of  hyperostosis  is  the  history  of  certain 
of  the  phenomena  of  inflammation  ;  there  is,  from  some  cause  or 
other,  irritation  attended  with  vascular  changes,  the  effusion  of  plas- 
tic matter  succeeded  by  the  osseous.  What  this  source  of  irritation 
is,  and  how  to  control  it,  are  matters,  unfortunately,  too  often  beyond 
our  conceptions. 

Reference  has  been  made  on  a  preceding  page  to  the  hypertro- 
phies of  the  specific  conditions  ;  such  enlargements  are  easy  enough 
to  understand,  even  if  not  so  easy  to  remove ;  but  the  hyperostoses 
here  considered  are  not  of  such  character,  but  seem  to  be  of  an  en- 
tirely local  signification ;  hence  a  local  source  of  offense  may  not  be 
sought  for  in  vain,  as,  for  example,  in  Mr.  Howship's  case,  where  the 
ostitis  might  very  plausibly  be  attributed  to  the  blows  received. 
The  inflammatory  thickening  of  bone,  alluded  to  a  few  pages  back  in 
connection  with  diseased  teeth  roots,  is  but  another  exhibition  of  the 
results  of  local  irritation. 

That  the  hyperostoses  are  to  be  viewed,  and  in  every  way 
treated,  as  simple  overgrowths,  is  certainly  well  exhibited  by  Mr. 
Quekett,  who,  submitting  to  microscopic  examination  portions  of  all 
the  osseous  tumors  in  the  Royal  College  of  Surgeons,  confirms  the 
position  in  all  particulars.    The  rates  of  the  growths  of  such  tumors 


360  ORAL  DISEASES  AND  SURGERY. 

are  I  presume,  influenced  by  individual  susceptibilities  or  peculiari- 
ties •  there  is  certainly  in  this  respect  the  greatest  possible  differ- 
ence. In  the  Osteographia  of  Mr.  Cheselden  is  the  engraving  of 
an  osseous  tumor  surrounding  the  head  of  a  tibia,  which  measures 
exactly  one  yard  in  circumference.  An  imposing  case  is  also  figured 
in  Mr.  Pagct's  Surgical  Pathology. 

In  this  growth,  as  Prof.  Clark  describes  it,  the  hardest  parts  have 
neither  Haversian  canals  nor  lacunae.  In  the  less  hard  parts  the  canals 
are  very  large,  and  the  lacunae  are  not  arranged  in  circles  around 
them,  and  everywhere  the  lacunas  are  of  irregular  or  distorted  form. 

Fig.  74. — Osseous  Tumor. 


The  above  remarkable  specimen  of  an  osseous  tumor  of  the  left 
upper  maxilla,  from  the  Traite  de  Pathologie  Externe,  found  in  the 
Musee  Dupuytren,  is  described  in  Mr.  Heath's  essay  as  being  lim- 
ited behind  by  the  pterygoid  process,  internally  by  the  intermaxil- 
lary suture,  above  and  externally  by  the  malar  bone.  The  tumor 
encroaches  considerably  upon  the  cavity  of  the  mouth,  and  reaches 
back  as  far  as  the  front  of  the  spine.  Its  form  is  bilobed,  and  in 
the  deep  sulcus  between  the  lobes  can  be  seen  a  molar  tooth.  All 
the  other  teeth  of  the  jaw  have  disappeared,  and  there  is  no  trace  of 
their  alveoli.  The  left  orbit  and  nasal  fossa  are  not  sensibly  dimin- 
ished in  size,  but  the  cavity  of  the  mouth  is  almost  entirely  occupied 
by  the  posterior  lobe  of  the  tumor.  The  lower  jaw  has,  in  this 
case,  undergone  several  remarkable  alterations.  It  must  at  first  have 
pressed  upon  the  growth,  and  produced  the  deep  sulcus  between  the 
lobes;  but  in  its  turn  the  tumor  has  reacted  upon  the  lower  jaw  with 
the  following  effect:  it  has  caused  a  double  luxation  of  the  jaw,  the 
left  condyle  resting  against  the  root  of  the  zygoma,  and  the  glenoid 
cavity  being  filled  with  soft  material.     The  teeth  of  the  left  side  of 


EXOSTOSIS,  ETC.  3gl 

the  lower  jaw  have  disappeared,  and  absorption  of  part  of  the  coro- 
noid  process  and  the  whole  of  the  alveolus  has  taken  place,  so  that 
only  the  base  of  this  part  of  the  bone  is  left.  The  outer  surface  of 
the  tumor  is  smooth,  and  presents  numerous  vascular  grooves  of 
good  size ;  at  many  points  it  is  perforated  with  holes.  The  vascu- 
larity of  the  other  bones  of  the  face  does  not  appear  to  be  aug- 
mented. 

In  Guy's  Hospital  Reports,  Mr.  Hilton  describes  a  case  in  which 
a  tumor  similar  in  signification  to  the  one  just  described  sponta- 
neously separated  from  the  face.  The  patient  was  a  man  aged 
thirty-six,  who,  twenty-three  years  before  Mr.  Hilton  saw  him, 
noticed  a  pimple  below  the  left  eye,  close  to  the  nose,  which  he  irri- 
tated, and  from  that  spot  the  tumor  appears  to  have  originated. 
The  tumor,  in  its  growth,  displaced  the  eyeball,  giving  rise  to  ex- 
cruciating pain,  which  subsided  on  the  bursting  of  the  ball.  It 
began  to  loosen  by  a  process  of  ulceration  around  its  margin  six 
years  before  it  fell  out,  which  event  was  unattended  by  bleeding  or 
pain.  The  tumor  weighed  14|  ounces.  It  was  tuberculated  exter- 
nally, and  an  irregular  cavity  existed  at  the  posterior  part.  A  sec- 
tion presented  a  very  hard,  polished  sui'face,  resembling  ivory,  and 
exhibited  lines  in  concentric  curves,  enlarging  as  they  were  traced 
from  the  posterior  part.  The  huge  cavity  left  by  the  tumor  was 
bounded  below  by  the  floor  of  the  nose  and  antrum,  above  by  the 
rontal  and  ethmoid  bones,  internally  by  the  septum  nasi,  and  exter- 
nally by  the  orbit,  which  had  been  considerably  encroached  upon  by 
the  tumor. — Heath'' s  Essay. 

THE    TUMEFACTION   OF  CARIES. 

Still  another  form  of  the  inflammatory  tumor  is  that  frequently 
associated  with  caries.  These  enlargements  are  the  result  of  un- 
derlying pus  and  debris,  which,  instead  of  forcing  a  vent,  lift 
off  the  tissue  from  the  bone.  It  might  be  thought  that  such  tume- 
factions would  not  be  at  all  dilficult  to  diagnose,  but  this  would  be 
found  an  error,  as  the  thickening  of  the  walls  of  the  tumor  is  not 
unfrequently  so  great  as  to  give  the  feel  of  a  solid  body;  then, 
again,  ragged-looking  fistulaeoccasionally  exist,  which,  when  probed, 
do  not  lead  with  any  directness  to  the  diseased  bone  ;  while  still 
again  it  happens  that  there  is  no  carious  bone  to  lead  to,  as  the  dis- 
ease has  ended  in  necrosis,  and  some  perhaps  insignificant  sequestrum 
has  concealed  itself  by  an  encystment  in  the  walls  of  the  tumor. 


CHAPTER    XXI Y. 


THE    EPULIDE8. 


Epulis. — The  derivation  of  this  word  is  from  the  Greek  em  ooXov, 
signifying  "  upon  the  gum." 

It  is  applied  by  common  consent,  or  rather,  I  should  say,  is  meant 
to  be  applied  to  a  class  of  tumors  having  origin  from  the  alveolo- 
dental  periosteum. 

In  the  study  of  these  tumors,  every  one,  I  presume,  has  felt  him- 
self more  or  less  confused  and  confounded.  It  would,  indeed,  be 
surprising  if  such  should  not  be  the  case,  considering  the  diversi- 
ties in  description  by  various  writers.  And  yet  these  discrepancies, 
numerous  as  they  are,  may  be,  I  think,  easily  explained  away. 

First.  I  will  take  it  on  myself  to  say  that  the  term  epulis,  when 
used  pathologically,  is  entirely  without  meaning  or  expression,  and, 
as  a  noun-substantive,  should  at  once  be  discarded  from  surgical 
nomenclature.  There  is  no  special  disease  which  can  be  called 
epulis,  and  called  so  with  a  distinctive  meaning.  Let  me  illustrate: 
salivary  calculi  rest  upon  the  gum  (e-t  ouXov).  Is  not  therefore  a 
calculus  an  epulis  ? 

The  term  is  inadequate  in  expression,  used  as  a  noun,  and  must 
ever  remain  so,  because  from  the  alveoli  of  the  teeth  grow  tumors 
of  various  signification.  Thus,  we  have  fibroid,  the  fibro-rccurring, 
the  myeloid,  the  polypoid,  the  encephaloid  or  carcinomatous,  the 
simple  pulp  fungoid,  etc.  Hence  the  confusion  which  marks  the 
writings  of  nearly  all  authors  on  the  subject — each,  without  prefa- 
tory explanation,  describing  the  various  growths  under  one  common 
head.  Take  even  Mr.  Fergusson,  so  eminent  as  an  oral  surgeon,  for 
example:  "Epulis,"  he  tells  us,  "is  a  disease  which  begins  as  a 
small  spot  on  either  the  outer  or  inner  surface  of  the  gums."  Again, 
he  says:  "Epulis  consists  of  a  swelling  of  solid  bone,  the  hard 
parts  of  the  bone  being  primarily  affected."  Again  :  "  Epulis  is  an 
osseous  cyst,  containing  a  glairy  or  a  serous  fluid."  He  also  in- 
stances a  polypus,  and  calls  it,  too,  an  epulis. 

Mr.  Paget,  on  the  contrary,  seems  to  ignore  the  existence  of  epulis. 
(362) 


THE   EPULIDES.  363 

Let  the  student  turn  to  his  history  of  the  myeloid  diseases,  and  see 
how  he  treats  our  £tti  oulov. 

I  have  studied  this  subject  closely ;  I  think  I  may  lay  claim  to 
being  familiar  with  most  authors  who  have  written  in  the  direction, 
and  I  have  satisfied  myself  that  the  various  discrepancies  are  only 
seeming;  that  all  differences  are  to  be  reconciled  simply  by  the  abne- 
gation of  the  word  epulis,  as  a  noun-substantive,  using  it  only  as 
an  adjectival-noun.  Let  me  illustrate :  suppose  the  spot  upon  the 
gum  to  which  Mr.  Fergusson  alludes  should  be  of  the  charac- 
ter of  epithelioma  —  then,  pathologically  speaking,  it  might  be 
cancer  ;  but,  being  situated  upon  the  gum,  ettj  ouXov,  it  would  also 
be  epulis.  Take  the  bony  tumors  (evidently  osteo-sarcomatous, 
as  in  our  classification  w^e  are  hereafter  to  study  them),  wait  until 
their  growth  shall  extend  so  as  to  emerge  from  the  gums,  they 
will  still  remain  sarcomatous,  but  they  will  also  have  become 
epulic. 

So  also  the  myeloid  tumors  instanced  by  Mr.  Paget  as  being  mis- 
taken for  the  epulides  ;  being  upon  the  gums  must  necessarily  have 
been  true  epulides,  and  those  who  disagreed  with  Mr.  Paget,  call- 
ing them  by  such  names  were  right — right  in  a  sense.  Yet  also  was 
Mr.  Paget  right. 

The  one  class  called  them  epulic,  because  they  were  situated 
upon  the  gums,  and  it  was  their  creed  so  to  call  all  tumors  so 
situated.  The  other  designated  the  growths  pathologically ;  the 
tumors  were  marrow-like,  the  situation  of  them  was  of  no  conse- 
quence. Now,  let  us  see  how  easy  it  would  seem  to  be  to  recon- 
cile these  different  descriptions  of  one  and  the  same  disease.  Sup- 
pose we  drop  the  word  epulis,  as  a  noun-substantive,  as  a  term 
having  pathological  meaning,  and  apply  it  in  accordance  with  its 
anatomical  derivation.  The  tumors  were  myeloid,  they  were  situ- 
ated upon  the  gums — we  will  call  them  "  epulo-myeloid ;"  is  not 
the  difference  here  reconciled,  and  is  not  the  compound  solidly  ex- 
pressive ?  An  epulo-myeloid  growth  is  a  tumor  situated  upon  the 
gums,  marrow-like  in  pathological  character.  Here  is  expressed  at 
once,  and  happily,  as  it  seems  to  me,  location  and  character. 

If  the  reader  is  prepared,  from  the  argument,  to  accept  of  the 
change  proposed,  all  confusion  will  be  found  to  have  disappeared. 
We  have  no  longer  any  tumor  of  the  mouth  which  we  know  as  an 
"epulis;"  but  we  have  epulo-myeloid,  epulo-fibroid,  epulo-fibro- 
recurring,  epulo-carcinoma,  or  whatever  other  class  of  tumor  patho- 
logically may  present  itself  to  us  situated  upon  the  gums.     By  such 


364  ORAL  DISEASES  AND  SURGERY. 

change  in  nomenclature,  we  make  this  pons  asinorum  an  easily- 
crossed  one ;  we  create  a  term  as  patent  to  the  scholar,  and  as 
expressive,  as  the  compound  expression  gastr-algia,  cephal-algia, 
gastr-itis,  cerebr-itis,  etc. 

History  of  a  few  Cases  Illustrative  of  Practice  in  this  Direction. 

Case  I. — Some  four  years  back,  Mrs.  T.,  the  sister  of  a  medical 
friend,  was  l)rought  by  the  brother  to  my  office  for  consultation  on  a 
tumor  (about  the  size  of  an  ordinary  pea)  growing  from  the  alveolus 
of  an  upper  molar  tooth.  I  thought  this  tumor  belonged  to  the  class 
pulp-fungoid.  There  was  the  broken  palatine  fang  in  the  jaw,  but 
so  deep  as  to  be  only  fairly  discernible  to  the  probe ;  I  could  not 
see  the  origin  of  the  growth,  but  inferred  its  character ;  by  separating 
carefully  the  alveolus  from  the  fang,  I  was  enabled,  after  some  little 
trouble,  to  get  the  root  from  its  bed.  The  little  tumor  proved  to 
be  an  outgrowth  of  the  periodontal  membrane,  and  not  an  excres- 
cence from  the  pulp ;  in  character  it  was  distinctly  and  decidedly 
fibrous — it  was,  then,  an  epulo-fibroid  tumor.  It  did  not  look  like  a 
growth  from  the  periosteum,  but  rather  as  if  its  origin  was  in  the 
crusta  petrosa,  and  it  had  carried  the  periosteum  before  it  somewhat 
like  the  infundibuliform  fascia  is  made  a  tunic  to  the  descending  in- 

FiG.  75. — Small  EpuLO-riBRoiD  Tumor — from  Life. 


testine  in  an  oblique  inguinal  hernia.  The  removal  of  the  fang 
brought  the  growth  cleanly  way ;  of  course,  no  scraping  or  cutting 
of  the  parts  was  at  all  necessary;  the  growth  was  evidently  an 
emanation  of  the  dental  aspect  of  the  periosteum,  and  had  in  no  way 
involved  its  alveolar  reflection.  Xo  treatment  of  any  kind  outside 
of  the  removal  of  the  tooth  was  employed ;  the  patient  remains  per- 
fectly cured. 


THE  EPULIDES.  365 

Case  II. — Mrs.  J.  presented  herself  some  time  in  1862,  with  a 
livid,  threatening-looking  tumor,  the  size  of  a  hickory-nut,  occupying 
the  left  alveolar  face  of  the  upper  jaw,  extending  from  the  lateral  inci- 
sor back  near  to  the  tuberosity.  This  tumor  diminished  in  size  during 
sleep,  and  increased  during  the  time  of  any  excitement  which  tended 
to  accelerate  the  circulation,  sometimes  seeming  like  a  solid  body,  at 
others,  like  a  spongy  mass  ;  it  evidently  was  erectile  in  its  nature, 
analogous  to  the  ordinary  naevi.     It  was  an  epulo-erectile  tumor. 

Fig.  76. — Eptjlo-Erectile  Tumor. 


Separating  the  growth  from  the  gum,  its  association  with  the 
periosteum  was  plainly  evident ;  while  the  probe  revealed  extensive 
caries  of  the  neighboring  bone.  An  operation,  which  resulted  in 
complete  cure,  was  performed  as  follows :  the  lip  being  held  well 
out  of  the  way  by  an  assistant,  an  incision  was  made,  extending 
from  the  central  incisor  tooth  of  the  affected  side  back  to  the  tuber- 
osity, a  similar  cut  being  carried  back  on  the  palatine  face  of  the 
tumor  to  the  place  of  beginning:  these  cuts  were  made  freely  through 
the  soft  parts  down  to  the  bone,  and  completely  circumscribed  the 
tumor,  with  a  reasonable  margin  to  spare.  The  central  incisor  was 
next  extracted,  and,  with  the  ordinary  cutting-forceps,  a  cut  was 
made  through  its  alveolus,  extending  almost  to  the  labio-nasal  angle. 
A  second  pair  of  cutting-forceps  was  now  taken  up,  and  by  two  cuts 
the  width  of  its  blades,  the  involved  bone  was  removed  ;  the  section 
extending,  as  is  evident,  from  the  situation  of  the  left  central  incisor 
to  the  tuberosity.  Considerable  hemorrhage  attended  the  operation, 
although  the  section  was  well  outside  of  the  vessels  involved,  three 
ligatures  being  required. 

After- Treatment.— l^hQ  lady  being  of  very  full  habit  and  of 
markedly  sanguine  temperament,  magnesia  sulph.  gss  was  ordered 
the  evening  of  the  operation.     As  an  opiate,  morph.  sulph.  gr.  ss. 


366  ORAL  DISEASES  AND   SURGERY. 

Day  after  Operation. — Marked  inflammatory  action,  attended  with 
considerable  swelling  of  the  tissues  of  the  face. 

B. — Plumbi  acet.  5ij ; 
Tinct.  opii,  ^ij ; 
Aqua,  ^xvi. 

Ordered  a  cloth  wet  with  the  preparation  to  be  kept  continuously 
upon  the  face. 

Third  day.  Inflammation  increasing ;  eyes  completely  closed  from 
the  great  oedema  of  the  lids ;  mag.  sulph.  reordered,  with  hot  pedi- 
luvia ;  eyelids  heavily  painted  with  tinct.  iodine. 

Fourth  day.  Erysipelas  set  in ;  the  face  looking  like  a  glistening 
red  ball ;  patient  restless,  nervous,  and  frightened ;  painted  the 
whole  face  with  tinct.  iodine,  oflScinal  strength ;  the  lead-water  and 
laudanum  continued  ;  iron  and  quinine  internally. 

B. — Tinct.  ferri  chl.  Jiij  ; 
Quinia  sulph.  grs.  xxv. 
Sig.  Fifteen  drops  in  water  every  three  hours. 

Also  a  diaphoretic. 

B. — Liq.  ammoniae  acetatis,  gij. 
Sig.  Tablespoonful  every  ten  minutes  until  profuse  perspiration  is 
induced. 

Sirth  day.  Erysipelas  evidently  yielding ;  iron  and  quinine  ;  paint- 
ing with  iodine,  lead-water,  and  laudanum,  continued. 

Seventh  day.  Much  improved;  the  erysipelatous  redness  gone; 
skin  wrinkling ;  patient  can  see  a  little  from  one  eye ;  continued  the 
painting  with  the  iodine,  and  the  application  of  the  lead-water  lotion. 

Ninth  day.  Inflammation  all  gone  ;  patient  quite  comfortable ;  the 
exposed  bone  covered  with  a  thin  layer  of  healthy  granulations ; 
case  progressing  well. 

Twelfth  day.  Patient  attending  to  household  duties  ;  mouth  of 
course  very  tender,  but  advancing  toward  a  cure  rapidly. 

Twenty-fifth  day.  Patient  may  be  called  well ;  needs  no  further 
attention. 

To  complete  the  case,  artificial  teeth  have  been  inserted,  the  plate 
being  made  to  fill  up  the  place  of  the  lost  bone.  No  one  would 
ever  suppose,  in  looking  at  the  lady,  she  had  lost  such  a  portion  of 
the  jaw. 

Case  ITT._Mrs.  S.,  of  Camden,  N.  J.  Epulo-fibroid  tumor  of  left 
superior  maxilla.     This  tumor  was  the  size  of  a  large  walnut,  the 


THE  EPULIDES.  367 

bulging  of  the  clieek  from  its  presence  quite  deforming  the  patient; 
growing  very  rapidly  ;  painless.  Patient  had  been  confined  with  her 
fourth  child  five  weeks  before  presenting  herself 

Operation. — This  was  performed  three  weeks  later,  the  infant 
being  eight  weeks  old.  The  tumor,  or  all  that  portion  of  it  which 
was  free  of  the  bone,  was  cleanly  removed  with  the  scalpel,  together 
with  a  margin  of  surrounding  healthy  tissue.  This  step  exposed 
the  bone,  which  was  found  carious.  This  was  to  be  removed,  and 
which  was  easily  and  happily  effected  through  the  use  of  the  gouge, 
little  by  little  being  cut  away  until  healthy  structure  was  exposed. 
The  surgeon  recognizes  such  healthy  structure  both  by  its  feel  under 
the  instrument,  and  its  appearance  ;  healthy  living  bone  being  white, 
studded  with  minute  bleeding  points.  Hemorrhage  during  the  oper- 
ation was  considerable,  but  was  controlled,  without  ligature,  simply 
by  throwing  alum-water  into  the  wound  from  an  ordinary  syringe. 

After-  Treatment. — Very  little  required  ;  a  wash  of  the  perman- 
ganate of  potash,  five  grains  to  the  ounce  of  water,  was  given  as  a 
disinfectant,  there  being  for  a  few  days  a  somewhat  disagreeable 
odor  from  a  decomposing  blood  clot.  No  antiphlogistics,  or  systemic 
treatment  of  any  kind  was  required,  not  a  bad  symptom  having  ap- 
peared, the  patient  being  entirely  well  in  three  w'eeks  from  the  day 
of  operation.  In  this  case  the  floor  of  the  antrum  was  removed  and 
the  cavity  wholly  exposed.  At  the  completion  of  the  cure,  it  was, 
however,  closed  up. 

Case  IV. — Mrs.  T.,  West  Chestnut  Street.  Tumor  of  four  years' 
growth  ;  loosely  fibrous  in  structure,  occupying  one-half  of  the  roof 
of  the  mouth,  giving  a  most  disgusting  and  threatening  appearance. 
The  growth  had  first  appeared  between  the  bicuspid  and  first  molar 
teeth,  and  at  the  time  of  my  first  seeing  it,  had  entirely  destroyed 
the  inner  alveolar  plate  of  all  the  portion  of  the  jaw  with  which  it 
was  associated.  In  raising  the  tumor  from  its  bed,  all  the  under- 
lying palatine  process,  as  far  as  could  be  seen,  was  found  to  be 
diseased. 

Operation. — This  consisted  in  cutting  away  as  much  of  the  growth 
with  the  scalpel  as  possible,  and  completing  the  operation  on  the 
bone  with  the  gouge  ;  the  hemorrhage  very  profuse,  the  use  of  a  com- 
press being  necessary  for  its  arrestation  ;  and  this  only  effected  after 
several  hours.* 

*  Hemorrhage  sometimes  attends  these  operations  where  the  ligature  cannot 
be  applied,  and  wliere  it  is  not  expedient  to  employ  measures  which  are  apt 


368 


ORAL  DISEASES  AND  SURGERY, 


After- Treatment. — Very  little  required;  some  overinflammatory 
action,  but  which  quickly  and  readily  yielded  to  low  diet  for  a  few 
days,  and  a  single  dose  of  sulphate  of  magnesia.  In  three  weeks 
the  case  was  in  condition  to  be  dismissed. 

Case  T. Mrs.  C,  colored.    Epulo-fibro-recurring  tumor  of  upper 

jaw ;  had  been  twice  imperfectly  removed  by  her  physicians ;  the 
osseous  structure  in  neither  instance  being  included  in  the  opera- 
tion. Tumor  the  size  of  a  small  orange,  and  involving  the  whole 
antrum  of  the  affected  side.  Proposed  the  removal  of  the  whole 
maxilla,  the  only  operation  which  I  conceived  promised  permanent 
relief     The  operation  was  objected  to  by  the  patient. 

History  of  Case. — Day  by  day  the  tumor  increased  in  volume ; 
soon  the  floor  of  the  orbit  was  thrown  up  and  the  eye  protruded 
upon  the  cheek ;  a  short  time  longer  and  the  growth  passed  into  the 
cranial  cavity,  destroying  the  patient. 

Case  YI. — Recurring  epulo-fibrous  tumor.  These  two  views,  from 
life,  represent  the  case  of  a  young  lady  as  an  epulic  tumor  appeared 


Figs.  77  and  78. — Epulic  Tumors. 


when  first  operated  on,  and  as  it  reappeared  and  was  reoperated  on 
some  four  months  after  the  first. 

I  subjoin  the  history,  because  it  exhibits  what  experience  will 
designate  as  a  proper  mode  of  practice  in  such  cases. 

The  patient,  a  young  lady  of  much  more  than  ordinary  personal 
attraction,  applied  for  treatment  of  the  tumor  as  represented  in  the 
first  view.  The  necessity  for  an  operation  being  explained  to  patient 
and  parents,  I  made  the  following  suggestions :  First,  that  a  section 

to  be  attended  with  secondary  bleedings,  as,  for  example,  the  acutal  cautery. 
In  this  case  the  compress  was  made  of  a  tuft  of  cotton,  saturated  with  alum- 
water. 


THE  EPULIDES.  369 

be  made  which  should  simply  remove  the  tumor  and  alveolar  pro- 
cess connected  with  it.  If  this  should  succeed,  there  would  be 
no  deformity.  Second,  if  the  growth  should  reappear,  then  a  second 
operation  to  be  performed,  which  should  remove  the  bone  proper, 
except  a  simple  rim  of  continuity.  Third,  if  this,  too,  should  fail, 
then  the  complete  section  of  the  bone  to  be  made  ;  this  of  course 
would  be  deforming,  but  it  would  be  the  only  resource. 

In  December,  1866,  the  first  of  the  operations  was  performed;  the 
bone  outside  the  section  looked  perfectly  healthy,  and  gave  every 
promise  of  a  satisfactory  result.  In  two  weeks  healthy  granulations 
had  covered  the  bone,  and  in  one  month  the  patient  was  dismissed 
cured.  The  following  March,  however,  a  small  tubercle  ^appeared 
in  the  very  center  of  the  site  of  the  original  tumor,  and  in  the  course 
of  three  weeks  half  a  dozen  new  tumors  or  lobules  had  sprung  up. 
The  second  operation,  as  proposed,  was  now  performed,  the  conti- 
nuity and  natural  arch  of  the  bone  being  preserved  unbroken.  This 
was  successful.  The  patient  now  (1869)  remains  perfectly  well. 
The  site  of  the  removed  bone  being  occupied  by  artificial  teeth, — not 
the  slightest  deformity  is  to  be  observed. 

Fig.  79. — Skction  ov  Eone  as  first  and  afterward  made. 


This  is  a  type  of  many  similar  ones  that  have  occurred  in  my 
experience.  It  might  be  thought  the  better  practice  to  make  the 
deep  section  first.  It  may  be  that  this  is  so,  but  the  first  operation 
is  so  very  simple  compared  with  the  second,  is  so  quickly  done,  and 
with  so  little  shock  or  risk,  and  is,  withal,  so  frequently  successful, 
that  the  mean  of  my  cases  indorses  the  practice  suggested. 

The  history  of  the  epulides  is  progressiveness.  The  case  repre- 
sented exhibits  the  disease  in  what  might  be  termed  its  incipiency. 
When  the  bone  in  its  whole  thickness  has  become  involved  in  the 
morbid  condition,  there  is  but  the  single  operation  that  promises  any 
hope  of  cure,  and  that  is — complete  and  full  section. 

Fig.  80  represents  the  celebrated  case  of  Mary  Griffiths,  operated 
on  by  Mr.  Liston  in  1836.  The  following  summary  of  it  is  given 
by  Mr.  Liston  in  a  paper  on  Tumors  of  the  Jaw: 

The  patient  had  labored  under  the  disease  for  eight  years,  and 

24 


370  ORAL  DISEASES  AND   SURGERY. 

had  been  sulycct  to  a  partial  removal  of  the  growth  when  of  incon- 
siderable size.  The  tumor  was  of  fibrous  nature  as  regards  its  dis- 
position, form,  and  intimate  structure.  It  differed  somewhat,  how- 
ever, in  outward  appearance,  in  consequence  of  its  exposed  situation. 

Fig.  80. — Fibrous  Epulis  of  Upper  Jaw. 


The  growth  sprang  originally  from  the  gums  and  sockets  of  the  in- 
cisors and  canine  teeth  of  the  left  side  ;  at  an  early  period  it  pro- 
truded from  the  mouth,  unconfined  and  uninfluenced  by  the  pressure 
of  the  lips  or  cheek.  It  had  assumed  a  most  formidable  size  and 
appearance,  concealed  the  palate  and  pharynx,  and  gave  rise  to  great 
inconvenience  and  suffering.  The  surface  had  been  broken  by  ul- 
ceration, but  upon  close  inspection  of  the  projecting  part,  and  of 
that  covered  by  the  cheek,  it  was  found  to  possess  a  firm  consistence, 
and  to  present  a  peculiar  botryoidal  arrangement  of  its  parts. 
An  operation  proved  perfectly  successful. 


CHAPTER    XXV. 


OSTEO-SARCOMA. 


However  much — and  it  may  be  justlj — the  term  osteo-sarcoma 
is  abused,  it  still  manages  to  hold  its  place  in  surgical  nomenclature. 
Employed  indiscriminately,  as  it  long  has  been,  it  must  certainly  be 
perplexing  enough  to  that  class  of  professional  men  who  study 
names  and  shadows  rather  than  the  substance  of  things ;  for,  like 
the  word  epulis,  osteo-sarcoma  has  been  made  to  represent  the  most 
unlike  pathological  conditions,  and  the  greatest  diversity  of  features. 

The  term,  as  is  seen,  is  a  compound  one,  and  is  derived  from  the 
Greek  dariuv,  signifying  bone,  and  adp^,  meaning  flesh  ;  and  by  those 
who  created  the  term,  could  only  have  been  intended  to  stand  as  the 
representative  of  a  class  of  tumors  which  were  fleshlike  in  appear- 
ance, either  fleshy  tumors  in  or  upon  bony  structures,  or  a  transform- 
ation of  bone  into  fleshy  substance. 

I  cannot  say  that,  to  me,  the  term  seems  such  an  ill  one  ;  it  is  cer- 
tainly expressive;  it  is  no  fault  of  the  word  that  men  will  misuse  it. 
Be  it  as  it  may,  however,  there  are  so  great  a  number  of  oral  tumors 
which  are  made  to  come  within  its  classification,  that  no  direction  of 
our  study  demands  from  us  a  closer  understanding ;  and  such  under- 
standing implies  that  we  should  look  at  the  subject  from  every  stand- 
point. 

Osteo-sarcoma  cannot,  from  its  origin,  apply  to  a  strictly  special 
disease ;  it  is  a  noun  of  multitude,  just  as  is  epulis  when  it  is  used 
as  a  noun.  We  speak  of  the  human  face  when  we  would  direct  at- 
tention to  the  countenance ;  so,  also,  we  speak  of  the  face  of  a  land- 
scape, the  face  of  the  moon,  or  the  face  of  things  generally.  Now, 
the  word  face  is,  without  doubt,  a  very  admirable  word,  but  still  it 
tells  nothing  of  the  many  different  kinds  of  faces.  To  be  special,  it 
must  have  some  adjectival  prefix.  With  such  prefix  we  get  every 
proper  shading  of  the  expression,  and  can  employ  it  freely  to  our  own 
satisfaction,  and  to  the  making  of  ourselves  perfectly  understood  by 
others.  Thus,  we  say  of  one  man  that  he  has  a  bright  face,  of  an- 
other that  he  has  a  dull  face,  etc.     Osteo-sarcoma  requires  equal 

(371) 


372  ORAL  DISEASES  AND   SURGERY. 

latitude.  Tims  we  have  a  fleshy-looking  tumor  which  is  benign; 
and  we  have  another  which  is  malignant.  Both  of  them  are  sarco- 
matous, inasmuch  as  they  are  fleshlike ;  yet  they  are  very  different 
kinds  of  tumors,  so  far  as  a  prognosis  would  be  concerned. 

By  the  term  "fleshlike,"  I  do  not,  however,  understand  that  mus- 
cle-like structure  is  specially  implied  ;  as  all  descriptions,  however 
far  back  I  have  been  able  to  go,  seem  to  refer  rather  to  an  imperfect 
sort  of  fibrous  or  fil)ro-plastic  tissue. 

Prof.  Gross,  speaking  of  the  diseases  of  the  maxillary  bones 
which  seem  to  require  the  operation  of  excision,  says  they — the 

diseases are  generally  described  under  the  vague  and  unmeaning 

name  of  ostco-sarcoma,  and  constitute  a  group  of  affections  defying 
every  attempt  at  correct  classification.  That  this  declaration,  he 
says,  is  not  a  mere  assumption  unsupported  by  facts,  the  writings  of 
pathologists  and  surgeons  al)undantly  testify. 

Prof.  Henry  H.  Smith,  in  his  Surgery,  page  483,  thus  writes  on 
osteo-sarcoma :  the  bony  and  fleshy  tumor,  or  osteo-sarcoma,  is  an- 
other ancient  name,  sometimes  indiscriminately  applied  to  a  tumor 
analogous  to  spina  ventosa.  Both  these  tumors  are  malignant  in 
their  character,  and  would  be  better  designated  as  enchondromata, 
or  as  cancer  of  bone,  the  growth  being  generally  due  to  a  deposit  of 
carcinomatous  matter  in  the  bone,  causing  an  expansion  both  of  its 
compact  and  cancellated  tissue.  In  spina  ventosa,  he  says,  the 
greatest  development  is  of  the  cancellated  structure  ;  while  in  osteo- 
sarcoma it  is  rather  the  compact  layer  and  the  external  pei'iosteum 
that  are  involved,  the  cancellated  tissue  being  filled  with  a  fleshy 
carcinomatous  structure ;  while  the  enlarged  cells  are  sometimes 
also  filled  with  limited  effusions  of  blood,  or  a  lardaceous,  soft, 
pulpy  deposit. 

Mr.  Fergusson  says  the  non-malignant  or  benign  tumors  are  rep- 
resented by  what  Mr.  Abernethy  calls  simple  sarcoma.  These  are 
tumors  of  a  solid  fleshy  character  throughout ;  or  they  may  consist 
of  a  bag  or  cyst,  which  contains  fluid,  or  of  a  combination  of  these 
two,  for  there  may  be  one  cyst  or  more  in  a  tumor  whose  general 
character  is  sarcomatous  ;  and  in  another  case  a  cyst  may  ultimately 
assume  the  appearance  of  a  more  solid  growth. 

Prof.  Gross,  in  his  work,  "  Gross  on  the  Bones,"  defines  osteo- 
sarcoma as  an  alteration  of  the  osseous  tissue,  in  which  the  sub- 
stance of  the  bone  is  converted  into  a  mass  more  or  less  analogous 
to  cancer  of  the  soft  parts.  The  origin,  he  says,  is,  in  most  cases, 
referable  to  an  hereditary  disposition  or  to  external  violence  ;  it  gen- 


OSTEOSARCOMA.  373 

erally  comes  on  with  deep-seated,  lancinating  pains,  which  continue 
a  considerable  time  before  there  is  any  evident  enlargement  or 
swelling.  The  form  of  the  tumor  he  describes  as  either  smooth 
and  circumscribed,  or  unequal,  and,  as  it  were,  tuberculated,  etc. 
For  continuation  of  this  paper,  see  his  book,  page  181. 

Eustachius  speaks  of  certain  calcareous  concretions  deposited 
about  the  necks  of  the  teeth  (tartar  or  salivary  calculi  evidently), 
and  Mauget  classes  such  concretions  with  the  sarcomatous  growths. 

Prof.  Dunglison,  in  his  dictionary,  defines  osteo-sarcoma  as  a  dis- 
ease of  the  bony  system,  which  consists  in  softening  of  its  laminae, 
and  their  transformation  into  a  fleshy  substance  analogous  to  that  of 
cancer,  accompanied  with  general  symptoms  of  cancerous  affection. 

Mr.  Paget  says  the  name  of  cartilaginous  tumor  may  be  given  to 
those  which  Miller,  in  one  of  the  most  elaborate  portions  of  his 
work  on  cancer,  has  named  enchondroma.  In  a  foot-note,  Mr.  Paget 
says  another  name  employed  for  these  tumors  is  benign  osteo-sar- 
coma. In  a  second  foot-note  he  says,  under  the  vague  name  osteo- 
sarcoma many  include  together  and  seem  to  identify  all  growths  in 
which  bone  is  mingled  with  softer  tissue. 

Miller,  in  his  "  Principles  of  Surgery,"  says  by  the  term  osteo- 
sarcoma is  understood  a  tumor  composed  partly  of  bone  and  partly 
of  fleshy  suljstance,  as  the  name  ini})lies :  the  latter  constituent  of  a 
simple,  non-malignant  character.  The  formation  is  usually  attribu- 
table to  external  injury,  perhaps  slight,  and  originates  in  the  cancel- 
lous texture  of  the  bone.  The  osseous  part  is  analogous  to  the 
fibrous  interlacement  in  tumors  of  the  soft  parts.  It  is,  as  it  were, 
the  stroma,  in  which  the  other  constituent  is  deposited,  dense  and 
solid,  centrally  radiating  in  spiculse  outward,  w^hich  always  diverge 
and  interlace,  leaving  interstices  more  or  less  wide,  in  which  the 
fleshy  substance  is  deposited,  etc.  See  page  442  for  differences,  as 
given  by  this  author,  between  osteo-sarcoma  and  enchondroma  and 
osteo-cephaloma,  etc. 

Lebert  places  the  whole  class  among  the  cancroid  growths,  and 
denies  that  tendency  to  return  furnishes  any  sufficient  evidence  of  a 
cancerous  origin. 

Miller,  in  another  part  of  his  "  Principles  of  Surgery,"  says  he 
desires  candidly  to  admit  that  the  class  is  "not  certainly  a  well- 
defined  one."  It  has  been  doubted,  he  says,  whether  some  variety 
of  these  fibro-plastic  growths  would  not  be  more  properly  classed 
among  the  malignant  tumors,  as  they  have  been  found  prone  to  re- 
turn, after  excision,  with  singular  obstinacy. 


374  ORAL  DISEASES  AND  SURGERY. 

Spina  ventosa,  as  remarked  by  Prof.  Smith,  is  freely  enough  con- 
founded with  the  osteo-sarcomatous  growths.  Now,  the  first  is  a 
term  meant  to  imply  an  empty  cyst,  such  as  on  a  previous  page  I 
described  as  simple  cysts :  ventosa,  a  word  from  the  Arabic,  signify- 
ino-  windy;  while  the  latter  implies  a  solid,  or  comparatively  solid, 
tumor.  This  definition  difi"ers,  I  am  aware,  from  that  given  by  Prof 
Smith;  but  I  employ  the  term,  and  recognize  it  only  in  accordance 
with  its  literal  meaning.  If,  then,  spina  ventosa  means  a  sharply- 
defined  empty  cyst,  or,  to  give  another  definition  to  the  prefix  spina, 
"a  cystic  tumor  accompanied  with  pricking  pains,"  then  it  cannot 
simulate  so  as  not  to  be  recognized. 

And  so  I  might  go  on  through  all  the  authors  upon  my  shelves — 
each  one  describes  the  disease,  but  classifies  it  differently.  A  review 
which  I  made  of  many  authors  reminded  me  graphically  of  Brum- 
macher's  impressive  anecdote  of  the  bringing  of  the  priests  from 
the  Babylonian  war  by  Alexander:  "Bild  und  Zeichen  ist  nicht  das 
Wesen."  But  I  have  quoted  enough — and  have  chosen  authors 
presumed  to  be  familiar  to  my  readers — to  exhibit  the  confusion 
which  exists  in  the  nomenclature  of  this  direction  of  the  maxillary 
tumors,  and  to  excuse  me,  I  trust,  from  any  appearance  of  egotism 
in  choosing  my  own  terms  and  my  own  way  to  describe  these  dis- 
eases. I  do  not  know  that  I  shall  succeed  better  than  many  others 
in  making  myself  understood,  but  I  shall,  at  least,  adhere  strictly 
to  the  text,  and  map  out  the  tumors  as  I  have  met  with  them  in 
practice. 

I  choose,  then,  the  compound  osteo-sarcoma,  and  I  mean  the  term 
to  apply  to  a  class,  and  not  a  species.  I  mean  it  to  stand  as  the  repre- 
sentative of  any  tumor  in  or  upon  bone,  which  is  osseo-fibro-plastic. 
Let  that  tumor  be  benign  or  malignant — this  proposition  is  to  be 
distinctly  borne  in  mind. 

Osteo-sarcomatous,  or  osteo-fibro-plastic  (synonymous)  tumors  are 
to  be  esteemed  doubtful  growths.  Thus  I  have  seen  two  or  more 
alike,  to  the  unassisted  eye ;  yet  one  has  succumbed  readily  to  treats 
ment,  while  the  others  have  bid  defiance  to  every  operative  pro- 
ceeding, and  have  gone  on  to  the  destruction  of  the  patients.  In 
minute  structure  (pathological  character)  such  tumors  must  have, 
of  course,  varied  greatly. 

The  fibrous  tumors  of  the  jaws  described  by  Mr.  Paget — see  his 
Lectures  on  Surgical  Pathology — I  would  class  with  the  osteo- 
sarcomatous  ;  so  also  the  growth  which  he  describes  as  myeloid. 
(See  same  Lectures.)     Of  the  first,  he  says,  as  to  situation  and  con- 


OSTEOSARCOMA.  375 

venience,  the  fibrous  tumors  of  the  jaws  may  be  found  isolated  and 
circumscribed,  growing  within  the  jaw,  divorcing  and  expanding  its 
walls,  and  capable  of  enucleation ;  but  in  a  large  number  of  these 
tumors,  the  periosteum,  with  or  without  the  bone  itself,  is  involved, 
or  included  in  the  outgrowing  mass.  In  the  case  of  the  upper  jaw, 
either  the  periosteum  or  the  fibro-mucous  membrane  of  the  antrum, 
or  nasal  walls,  or  both  these,  may  be  included  in  such  a  tumor.  In 
all  these  cases  the  tumor  lies  close  upon  the  bone,  and  cannot  be 
cleanly,  or  without  damage  to  it,  separated,  except  on  the  outer  sur- 
face ;  commonly,  indeed,  bony  growths  extend  from  the  involved  bone 
into  the  tumor ;  and  sometimes  the  greater  part  of  the  bone  is  as  if 
broken  up  in  the  substance  of  the  tumor. 

The  character  of  these  growths,  Mr.  Paget  remarks,  is  easily  re- 
cognized in  the  fibrous  tumors  of  the  gums  and  alveoli. 

In  the  chapter  on  the  Epulides,  I  referred  to  a  tumor  which  is  a 
fibrous  outgrowth  from  the  alveolo-dental  periosteum.  This  same 
class  of  growths  spring  from  the  lining  membrane  of  the  sinus  max- 
illare,  and,  enlarging,  dispart  the  bones,  bulging  out  as  a  tumor  upon 
the  face :  they  are  osteo-sarcomatous  tumors,  or,  it  would  be  more 
correct  to  say,  sarcomatous  tumors,  purely  fibro-plastic  in  struc- 
ture, and  perhaps  exclusively  benign.  Such  growths,  if  early  and 
properly  removed,  are  not  apt  to  return.  I  have  met  with  these 
tumors  over  and  again  ;  they  always  seemed  to  me  to  have  asso- 
ciation with  the  bone  only,  when  such  association  was  forced,  as  it 
were,  on  them.  Such  tumors  are  exclusively  periosteal  in  their  im- 
mediate relationship.  I  have  examined  them  with  the  microscope, 
but  have  found  them  made  up  almost  exclusively  of  simple  fibrous 
tissues.  If  these  tumors  have  not  advanced  too  far,  you  will  see 
them,  on  taking  away  the  outer  wall  of  the  antrum,  as  some  foreign 
body  which  has  been  impacted  closely  within  the  part ;  they  have 
not  the  slightest  pathological  association  with  the  bones,  if  we  ex- 
cept their  periosteal  pedicel  or  base.  Indeed,  such  seems  the  tend- 
ency to  exclusiveness,  on  the  part  of  these  growths,  that  I  have 
seen  them  when  they  were  as  large  as  a  fcetal  head,  the  integument 
of  the  cheek  alone  covering  them,  the  bone  which  must  have  orig- 
inally formed  their  external  envelope  having  completely  disappeared 
through  absorption.* 

The  myeloid  tumors  of  Mr.  Paget  seem  to  me  justly  classible  with 
the  sarcomatous,  inasmuch  as  they  so  closely  resemble  fibro-plastic 


*  These  tumors  are  not  the  polypi  of  the  antrum. 


376  ORAL  DISEASES  AND  SURGERY. 

structures  as  to  lead  to  the  inference  that  such  portions  as  seem 
marrow-like  are  rather  the  result  of  retrograde  metamorphosis— a 
metamorphosis  into  the  medullary  type  of  carcinoma—than  of 
original  pathological  development.  It  was  on  account  of  their 
being  made  up  of  the  fiber  cell  that  M.  Lebert  gave  such  growths 
the  name  "  fibro-plastic." 

I  do  not,  however,  presume  to  dispute  pathology  with  Mr.  Paget: 
so  far  as  the  purpose  of  our  present  classification  is  concerned,  I 
have  only  to  do  with  the  fleshy  appearance  of  these  tumors.  Mi- 
nutely they  may  have  been  made  up  of  marrow-like  substances,  but 
if  in  general  appearance  they  are  fibro-plastic  or  fleshlike,  then  they 
belong  to  the  class  sarcomatous,  or,  when  found  associated  with  bony 
tissue,  osteo-sarcomatous. 

A  myeloid,  says  Mr.  Paget,  like  a  fibrous  tumor,  may  be  either 
inclosed  in  a  bone  whose  walls  are  expanded  round  it,  or,  more 
rarely,  it  is  closely  set  on  the  surface  of  a  bone,  confused  with  its 
periosteum.  The  sketches  of  fibrous  tumors  pictured  in  his  Sur- 
gical Pathology,  page  406,  might,  he  says,  be  repeated  for  myeloid 
tumors. 

Mr.  Paget  sets  down  these  two  kinds  of  tumors  as  being  equally 
common  to  the  jaws,  both  the  superior  and  inferior. 

AVhcn,  he  says,  the  myeloid  is  inclosed  in  bone,  the  tumors 
usually  tend  to  the  ovoid  or  spherical  shape,  and  are  well  defined, 
if  not  invested  with  distinct  thin  capsules  ;  seated  on  bone,  they  are 
(as  exemplified  by  the  epulic  structures)  much  less  defined,  less 
regular  in  shape,  and  often  deeply  lobed.  They  feel  like  uniformly 
compact  masses,  but  are  in  different  instances  variously  consistent. 
The  most  characteristic  examples  are  firm,  and  (if  by  the  name  we 
may  imply  such  a  character  as  that  of  the  muscular  substance  of  a 
mammalian  heart)  they  may  be  called  fleshy.  Others,  he  says,  are 
softer,  in  several  gradations,  to  the  softness  of  size  gelatin,  or  to 
that  of  a  section  of  granulations.  Even  the  firmer  are  brittle,  easily 
crushed  or  broken,  they  are  not  tough,  nor  very  elastic,  like  the 
fibro-cellular  or  fibrous  tumors,  neither  are  they  grumous  or  pulpy, 
neither  do  they  show  a  fibrous  or  granular  structure  on  their  cut  or 
broken  surfaces. 

Mr.  Paget  describes  sections  of  these  tumors  as  appearing  smooth, 
uniform,  compact,  shining,  succulent,  with  a  yellowish,  not  a  creamy 
fluid.  A  peculiar  appearance,  he  says,  is  given  commonly  to  them, 
by  the  cut  surface  presenting  blotches  of  dark  or  livid  crimson,  or  of 
a  brownish  or  a  brighter  blood  color,  or  of  a  pale  pink,  or  of  all  these 


OSTEOSARCOMA.  377 

tints  mingled  on  the  grayish-white  or  greenish  basis  color.  (In  a 
foot-note,  Mr.  Paget  quotes  from  Lebert,  who  says  the  greenish- 
yellow  color  that  may  show  depends  on  a  peculiar  fat,  xanthose.) 
The  tumors,  he  says  again,  may  all  be  pale,  or  have  only  few 
points  of  ruddy  blotching,  or  the  cut  surface  may  be  nearly  all  suf- 
fused, or  even  the  whole  substance  may  have  a  dull  modena  or  crim- 
son tinge,  like  the  ruddy  color  of  a  heart,  or  that  of  the  parenchyma 
of  a  spleen.  Mr.  Paget  believes  that  many  of  what  have  been 
named  spleenlike  tumors  of  the  jaws  have  been  of  this  kind.  The 
color  they  present,  he  says,  is  not  due  merely  to  blood  in  them  ; 
some  of  it  is  appropriate  to  their  texture,  as  is  that  of  the  spleen  or 
that  of  granulations,  and  it  may  be  quickly  and  completely  bleached 
with  alcohol. 

The  following  are  the  microscopic  appearances  which  Mr.  Paget 
says  are  peculiar  to  the  myeloid  growth,  being  imitated  in  no  other 
morbid  structure. 

1.  Cells  of  oval,  lanceolate  or  angular  shape,  or  elongated  and 
attenuated  like  fiber  cells,  or  caudate  cells,  having  dimly  dotted  con- 
tents, with  single  nuclei  and  nucleoli. 

2.  Free  nuclei,  such  as  may  have  escaped  from  the  cells,  and 
among  these,  some  that  appear  enlarged  and  elliptical,  or  variously 
angular,  or  are  elongated  toward  the  same  shapes  as  the  lanceolate 
and  caudate  cells,  and  seem  as  if  they  were  assuming  the  character 
of  cells. 

3.  The  most  peculiar  form  ;  large,  round,  oval,  or  flask-shaped,  or 
irregular  cells  or  cell-like  masses,  or  thin  disks  of  clear  or  dimly 
granular  substance,  measuring  from  one  three-hundredths  to  one- 
thousandth  of  an  inch  in  diameter,  and  containing  two  to  ten  or 
more  oval,  clear,  and  nucleolated  nuclei.* 

Corpuscles,  such  as  these,  in*egularly  and  in  diverse  proportions, 
imbedded  in  a  dimly  granular  substance,  make  up  the  mass  of  a 
myeloid  tumor.  They  may  be  mingled  with  molecular  matter,  or 
the  mass  they  compose  may  be  traversed  with  filaments  or  with 
bundles  of  fibro-cellular  tissue  and  blood-vessels,  but  their  essential 
features  (and  especially  those  of  the  many-nucleated  corpuscles)  are 
rarely  observed. 

Many  varieties  of  aspect  (as  remarked  by  Mr.  Paget)  may  thus 
be  observed  in  myeloid  tumors,  and  beyond  these  they  may  even  be 


*  These  microscopic  elements,  as  referred  to  in  the  chapter  on  Epulis,  are 
presented  on  page  449  of  "  The  Surgical  Pathology." 


378  ORAL   DISEASES  AND   SURGERY. 

so  changed  that  the  microscope  may  be  esseutial  to  their  diagnosis. 
After  they  partially  ossify,  well-formed  cancellous  bone  being  devel- 
oped in  them,  cysts,  also  filled  with  bloody  or  serous  fluids,  may  be 
formed  in  them,  occupying  much  of  their  volume,  or  even  almost 
excluding  the  solid  texture. 

Mr.  Paget  says  he  lately  amputated  the  leg  of  a  woman,  twenty- 
four  years  old,  for  what  was  supposed  to  be  a  cancerous  tumor 
growing  within  the  head  of  the  tibia.  She  had  pain  in  the  part  for 
eighteen  months,  and  increasing  swelling  for  ten  months,  and  it 
was  plain  that  the  bone  was  expanded  and  wasted  around  some  soft 
growth  within. 

On  section,  after  removal,  the  head  of  the  tibia,  including  its  ar- 
ticular face,  appeared  expanded  into  a  rounded  cyst  or  sac,  about 
three  and  a  half  inches  in  diameter,  the  walls  of  which  were  formed 
by  this  flexible  bone  and  periosteum,  and  by  the  articular  cartilages 
above ;  within  there  was  little  more  than  a  few  bauds  or  columns  of 
bone,  among  a  disorderly  collection  of  cysts  filled  with  blood,  or 
blood-colored  serous  fluids.  The  walls  of  most  of  the  cysts  were 
thin  and  pellucid;  those  of  others  were  thicker,  soft,  and  brownish 
yellow,  like  the  substance  of  some  medullary  cancers,  a  likeness  to 
which  was  yet  more  marked  in  a  small  solid  portion  of  tumor, 
which,  though  very  firm,  and  looking  fibrous,  was  pure  white  and 
brainlike. 

iS^one,  Mr.  Paget  says,  who  examined  this  disease  with  the  naked 
eye  alone,  felt  any  doubt  that  it  was  an  example  of  medullary  cancer, 
with  cysts  abundantly  formed  in  it.  But  on  minute  investigation, 
none  but  the  elements  of  the  myeloid  tumors  could  be  found  in  it ; 
these,  copiously  imbedded  in  a  dimly  granular  substance,  appeared 
to  form  the  substance  of  the  cyst  walls,  and  of  whatever  solid  mate- 
rial existed  between  them.  The  white  brainlike  mass  was  appa- 
rently composed  of  similar  elements  in  a  state  of  advanced  fatty 
degeneration,  but  neither  in  it  nor  in  any  other  part  could  be  found 
a  semblance  of  cancer  cell. 

Mr.  Paget  fails  to  inform  us  as  to  a  return  of  the  disease ;  it  does 
seem  to  me  that  in  the  present  state  of  our  knowledge  of  cancer 
growths,  it  would  have  been  a  very  difficult  matter  to  have  classed 
such  a  tumor  with  the  non-malignant.  It  certainly  was  very  hetero- 
clitic  in  character,  and  whatever  we  individually  may  feel  disposed 
to  think  of  such  a  structure,  it  serves  to  exhibit  the  merging  of  the 
benign  into  the  malignant,  and  their  relationship.  A  consideration 
of  such  cases  as  this  should  serve  to  keep  the  practitioner  on  his 


OSTEOSARCOMA.  379 

guard,  preventing  his  being  too  confident  in  any  prognosis  he  may- 
give  to  a  patient. 

An  epitome  of  the  myeloid  may  thus  be  presented: 

They  are  a  class  of  fleshy  tumors  called  by  M.  Lebert  fibro-plastic, 
because,  he  says,  they  are  made  up  of  fiber  cells.  They  are  called 
myeloid  by  Mr.  Paget,  because  he  thinks  they  much  more  resemble 
marrow  than  fibrous  tissue.* 

In  character,  according  even  to  Mr.  Paget,  they  vary  from  simple 
semi-fibrous,  semi-marrow-like  structures  to  those  so  heteroclitic 
that  they  seem  to  merge  into  the  medullary. 

Their  favorite  seat  seems  to  be  about  the  bones,  either  intra  or 
extra,  being,  perhaps,  more  common  to  the  maxilla  than  in  the  other 
osseous  structures. 

They  are  growths  which  usually  occur  singly,  they  are  more  fre- 
quent in  youth,  and  very  rare  after  middle  age ;  they  generally  grow 
slowly  and  without  pain,  and  usually  commence  without  any  known 
cause,  such  as  injury  or  hereditary  disposition. 

According  to  Mr.  Paget,  they  rarely,  except  in  portions,  become 
osseous  ;  they  have  no  proneness  to  ulcerate  or  protrude  ;  they  seem 
to  bear  even  considerable  injury  without  becoming  exuberant ;  they 
may  shrink  or  cease  to  grow ;  they  are  not  apt  to  recur  after  com- 
plete removal,  nor  have  they  in  general  any  features  of  malignant 
disease. 

Since  writing  the  above  I  have  accidentally  fallen  upon  a  classifi- 
cation of  the  tumors  of  the  upper  jaw,  made  by  Mr.  Hancock.  After 
alluding  to  various  classes,  he  says :  "  In  addition  to  these,  Mr. 
Paget  adds  what  he  terms  myeloid  tumors  of  the  part ;  but  while  the 
examples  he  quotes  resemble  on  the  one  hand  so  much  the  fibrous, 
on  the  other  the  medullary  tumors,  their  true  character,  whether  in- 
nocent or  malignant,  is  so  very  doubtful  that  I  should  hesitate  in 
admitting  them  as  a  distinct  class." 

I  am  pleased  to  quote  this  from  Mr.  Hancock.  There  are  already 
quite  enough  subdivisions  without  counting  in  such  as  can  be  done 
very  well  without.  Indeed,  it  is  because  I  so  prefer  a  general,  tangi- 
ble, rather  than  a  hair-splitting  classification,  that  I  am  disposed  to 
stick  to  the  embracing  term  of  sarcoma.  I  understand  pretty  well 
what  one  means  when  he  tells  me  of  an  osteo-sarcomatous  form 
of  growth ;  he  has  only  further  to  tell  me  whether  it  was  benign, 

*  Mr.  Paget  does  not  call  all  fibro-plastic  tumors  myeloid  ;  be  only  says  a 
myeloid  is  ditferent  from  tbe  ordinary  fibro-plastic  of  Lebert. 


380  ORAL  DISEASES  AND  SURGERY. 

disposed  to  malignancy,  or  already  malignant,  and  I  understand 
exactly  what  he  means. 

Fibrous  tumors  proper,  and  the  fibro-plastic,  have  general  features 

in  common, that  is,  they  belong  to  the  class  of  sarcomatous  growth  ; 

but  then,  in  a  pathological  sense,  they  have  such  differences  that  an 
epitome,  at  least,  of  their  history  should  be  reviewed  by  us. 

In  some  instances,  fibrous  tumors  are  seen  under  the  microscope 
to  have  a  concentric  development;  this  species  is  slowest  of  growth, 
is  most  benign,  and  never  attains  any  great  size. 

In  another  species  the  fibers  interlace  in  a  most  complicated  and 
irretj-ular  manner.  This  kind  attains  the  largest  size,  and  seems 
striding  toward  the  heteroclitic. 

A  third  class  consists  of  an  aggregate  of  nodules,  and  is  compared 
by  Dr.  Humphrey  to  a  conglomerate  gland  ;  the  tumor  being  made 
up  of  small  masses  closely  compressed  together,  having  an  uneven, 
knotty  outline. 

Fibrous  tumors  affecting  the  bones  (Braithwaite)  are  usually 
found  upon  those  of  a  spongy  nature,  upon  the  ends  of  the  long 
bones,  the  phalanges,  pelvis,  and  lo\ver  jaw.  (I  will  take  the  liberty 
here  to  correct  the  author.  I  have  described  these  tumors  as  as- 
sociated with  the  alveoli,  with  the  external  periosteum,  and  with 
the  antrum  of  Highmore,  and  I  know  that  they  do  thus  affect  both 
jaws,  as  I  have  met  with  them  often  enough  practically,  and  so  has 
every  one  who  has  had  any  extent  of  experience.)  So  far,  says  this 
author,  as  I  have  met  with  them,  they  are  confined  to  the  exterior 
of  the  lower  jaw,  growing  from  the  periosteum  and  creeping  along 
the  surface  of  the  bone  in  such  a  manner  as  to  prove  almost  to  a 
certainty  that  they  originate  in  some  morbid  condition  of  the  peri- 
osteal fibers.  The  bone  underneath  these  tumors  may  suffer  absorp- 
tion in  consequence  of  the  pressure  produced,  but  does  not  seem  to  be 
affected  in  any  other  way.  They  appear  upon  the  maxillary  bone 
more  frequently  than  upon  any  other  part  of  the  skeleton.  On  the 
lower  jaw  they  spread  along  the  ramus,  encircling  it  beneath  and  on 
the  sides,  so  that  the  bone  is  almost  concealed  by  the  tumor.  In  some 
instances  they  form  within  the  substance  of  the  jaw,  probably  from 
the  alveolo-dental  membrane,  and  as  they  increase,  the  walls  of  the 
bone  become  spread  out  over  them.  They  grow  up  around  the  teeth, 
and  when  they  project  into  the  mouth  may  be  soft  and  fungous.* 


*  Presenting  tliis  phase  the  tumor  may  be  classed  with  the  epulic,  but  it  is 
seen  that  on  this  account,  tiiere  need  be  no  confusion.  Many  epulic  tumors 
are  osteo-sarcomatt>us. 


OSTEOSARCOMA.  381 

In  some  instances  the  fibrous  tumors  of  the  jaws  exhibit  a  semi- 
cartilaginous  structure,  and  now  and  then  fibers  or  plates  of  bone 
are  formed  in  various  parts  of  them.  The  progress  of  the  disease 
is  well  illustrated  by  a  series  of  tumors  of  the  jaws  in  the  College 
of  Surgeons,  London,  from  the  museum  of  the  late  Mr.  Liston. 
These  preparations  serve  to  show  how  necessary  it  is  to  bear  in 
mind  the  mode  of  growth  of  these  periosteal  fibrous  tumors  of  the 
jaws,  because  from  their  disposition  to  creep  along  the  surface  of 
the  bone,  whether  it  be  an  endosteum  or  periosteum,  they  are  liable 
to  return  after  removal,  unless  the  immediately  adjacent  as  well  as 
affected  parts  be  excised.  The  histories  attached  to  the  specimens 
teach  that  very  large  fibrous  tumors,  both  of  the  upper  and  lower 
jaws,  together  with  the  bones  on  which,  or  in  which,  they  grow,  may 
be  successfully  removed. 

Now,  as  to  the  degeneration  of  sarcomatous  tumors,  it  is,  I  think, 
a  question  be3^ond  doubt  that  a  tendency,  greater  or  less,  to  retro- 
grade metamorphose  belongs  to  this  class.  I  need  only  instance 
the  m3'eloid  growths  of  Mr.  Paget,  just  considered.  Certainly 
nothing  could  more  closely  resemble  medullary  cancer,  in,  we  may 
say,  its  incipient  stage.  And  what  are  we  to  understand  of  the  re- 
curring fibrous  tumors,  if  there  is  no  carcinomatous  association  ? 

Concerning  the  diagnosis  of  the  sarcomatous  tumors,  and  the 
ability  to  follow  them  through  their  gradations,  it  seems  most  im- 
portant that  we  should  not  be  ignorant  of  the  distinguishing  signs 
that  exist. 

I  remarked  that  osteo-sarcoma  was  not  uufrequently  confounded 
with  spina  ventosa.  Now  the  point  at  which  these  two  different 
conditions  most  nearly  approach  each  other  is  in  the  hydatid  and 
other  cysto-sarcomatous  growths. 

Cysto-sarcoma,  as  implied  by  the  prefix,  is  a  tumor  of  only  semi- 
solidity,  its  interior,  or  stroma,  being  made  up  of  cysts  and  fleshy 
substance.  These  cysts  are  original  formations,  and  not  of  second- 
ary character, — that  is,  they  are  not  the  result  of  molecular  disin- 
tegration. They  are  lined  sacs,  having  a  distinct  secretory  mem- 
brane. Miller  describes  the  contents  of  these  cysts  as  widely 
differing,  and  which  every  one  must  have  observed :  "  They  are 
more  or  less  fluid,  sometimes  a  clear  gluey  liquid,  sometimes  a 
gelatinous,  pale  mass  of  semi-solid  consistence,  elastic,  and  project- 
ing beyond  the  level  of  the  cut  cyst  on  a  section  being  made  ;  some- 
times a  solid,  consisting  of  a  fibrous  deposit,  organized  very  imper- 
ectly,  if  at  all ;  sometimes  of  an  exanthematous  or  poppy  consistence, 


382  ORAL  DISEASES  AND  SURGERY. 

as  in  many  encysted  tumors ;  sometimes,  but  more  rarely,  a  dark  fluid, 
like  printer's  ink,  is  contained ;  sometimes  blood  is  mingled  with  the 
contents,  either  in  the  solid  or  in  the  coagulated  form." 

The  very  nearest  approach,  however,  made  by  cysto-sarcoma  to 
spina  ventosa,  is  in  that  class,  very  well  named  by  some  one,  as  I 
remember  to  have  seen,  the  "  cysto-succulent."  These  are  sarco- 
matous tumors,  the  stroma  of  which  is  made  up  of  very  loose  fibro- 
cellular  tissue.  They  might  well,  in  their  contents,  be  likened  to 
that  of  a  water-melon,  solid  enough  on  section,  but  compressible  to 
a  few  shreds.  The  fibrous  contents  of  the  stroma  are,  however, 
always  a  distinguishing  sign.  These  tumors  are  very  rare,  and  par- 
ticularly so  about  the  bony  structures. 

Miillcr  has  described  a  variety  of  these  cysts  of  sarcomatous 
growth,  which  he  calls  cysto-sarcoma  phyllodes.  "  The  tumor,"  he 
says,  "  forms  a  large  firm  mass,  with  a  more  or  less  uneven  surface. 
The  fibrous  substance,  which  constitutes  a  greater  part  of  it,  is  of  a 
grayish-white  color,  extremely  bard,  and  as  firm  as  fibro-cartilage. 
Large  portions  of  the  tumor  are  made  up  entirely  of  this  mass,  but 
in  some  parts  are  cavities  or  clefts,  not  lined  with  a  distinct  mem- 
brane (an  exception  to  the  rule  in  cystic  tumors).  These  cavities 
contain  but  little  fluid,  for  either  their  parietes,  which  are  hard,  like 
fibro-cartilage,  and  finely  polished,  lie  in  close  apposition  with  each 
other,  or  a  number  of  firm,  irregular  laminae  sprout  from  the  mass 
and  from  the  walls  of  the  fissures,  or  excrescences  of  foliated  or  wart- 
like form  sprout  from  the  bottom  of  the  cavities  and  fill  up  the  in- 
terior. These  excrescences  are  perfectly  smooth  on  their  surfaces, 
and  never  contain  cysts  or  cells.  The  laminae  lie  very  irregularly 
and  project  into  the  cavities  and  fissures  like  the  folds  of  the  psal- 
terium  in  the  interior  of  the  third  stomach  of  ruminant  animals. 
Sometimes  the  laminae  are  but  small,  and  the  warty  excrescences 
from  the  cysts  are  very  large,  while,  in  other  instances,  both  are 
greatly  developed." 

Cartilaginous,  or  the  enchondromatous  tumors  of  Miiller,  might, 
perhaps,  for  all  practical  purposes,  be  classified  with  the  sarcoma- 
tous, for  while  it  might  demand  some  little  stretch  of  the  imagina- 
tion to  convert  a  cartilage  into  looking  like  a  fleshy  mass,  yet  surgi- 
cally the  species  are  very  much  alike, — that  is,  both  are  reasonably 
benign,  both  are  little  amenable  to  the  action  of  the  sorbefacients, 
and  both  are  better  treated  by  the  knife  than  in  any  other  way. 

As  we  understand  the  osteo-sarcomatous  tumors  proper  to  be  out- 
growths associated  commonly  with  periosteal  membranes,  so  we  are 


OSTEOSARCOMA.  383 

led  naturally  to  ask  ourselves  as  to  the  cause  of  their  formation. 

This  I  conceive  to  be  twofold :  first,  as  the  result  of  local  irritation  ; 

I  second,  as  the  result  of  constitutional  conditions  ;  and,  still  again, 

:  we  may  combine  these  two,  laying  the  predisposing  cause  on  the 

I  one  and  the  exciting  on  the  other. 

'■  My  attention  was  once  directed  by  William  Gibson,  late  Professor 
'  of  Surgery  in  the  University  of  Pennsylvania,  to  a  case  markedly 
'  illustrative  of  this  latter  condition.  An  old  gentleman,  Mr.  F., 
seventy  years  of  age,  was  struck  on  the  cheek  by  a  stone.  He 
soon  had  growing  from  the  site  of  the  injury  a  tumor,  diagnosed 
by  Professor  G.  as  osteo-sarcomatous.  The  growth  of  the  body  was 
so  rapid  and  so  formidable  as  to  incline  to  the  view  of  its  intimate 
relationship  with  malignancy.  No  one  would,  I  think,  doubt  the 
twofold  relation  of  such  a  tumor. 

When  osteo-sarcoma  takes  on  this  rapid  growth,  its  innocency 
may  always  be  doubted  ;  when  the  development  is  slow  and  TCgular, 
and  particularly  if  the  origin  can  be  traced  to  some  local  irritant, 
extirpation  may  be  expected  to  result  in  a  complete  cure. 

When  these  tumors  are  fairly  and  openly  benign,  we  find  no  con- 
stitutional disturbance  associated  with  them,  at  least  none  that  are 
outside  of  strictly  mechanical  influences. 

Osteo,  or  simple  sarcomatous  tumors  of  the  sinus  maxillare,  should 
not  be  mistaken,  as  has  too  often  been  the  case,  for  polypi  of  the 
nares.  It  sometimes  happens  that  these  tumors,  particularly  the 
softer  kinds,  find  their  way  through  the  outlet  of  the  sinus  into  the 
nostril,  and  there  simulate  very  closely  a  common  fibrous  polypus ; 
such  tumors  have  been  often  highly  aggravated  by  operations  founded 
on  such  mistaken  diagnosis.  Again,  polypi  of  the  nostrils  may  find 
their  way  through  the  same  passage  into  the  sinus,  and,  enlarging, 
represent  very  fairly  the  ordinary  sarcomatous  tumor  of  that  cavity. 
Now,  pathologically  speaking,  being  about  one  and  the  same  thing, 
it  would  be  little  difference  where  or  how  the  growth  should  develop, 
but  as  operative  proceedings  are  concerned,  a  mistake  of  the  kind 
becomes  quite  an  awkward  matter. 

As  regards  changes  common  to  the  sarcomatous  tumors,  they  may 
be  considered  under  the  heads  of  softening,  suppuration,  and  ma- 
lignant degeneration. 

Softening,  says  Dr.  Humphrey,  appears  to  take  place  in  two 
ways: 

First,  as  a  chronic  process,  affecting  some  circumscribed  portion 
of  the  tumor,  which  is  usually  at  or  near  the  center.    The  change  is 


384  ORAL   DISEASES  AND  SURG  ERF. 

observed  to  commence  with  a  slight  discoloration,  a  yellowish  or  dark 
tinge,  which  is  followed  by  a  loosening  or  incipient  disintegration  of 
the  structure  ;  at  the  same  time  a  line  of  demarkation  is  formed 
around  the  altered  portion,  which  becomes  separated,  like  a  seques- 
trum, from  the  surrounding  mass.  Both  the  detached  portion  and 
the  cavity  are  at  first  rough  and  thready  on  their  opposed  surface ; 
the  former  undergoes  still  further  disintegration  and  solution,  be- 
coming broken  up  into  a  number  of  smaller  fragments,  which  float 
about  in  a  dark,  dirty,  turbid  fluid,  and  which  may  ultimately  dis- 
appear. 

The  process  of  destruction  may  go  on  in  the  adjacent  portion  of 
the  tumor,  enlarging  the  central  cavity  till  the  whole  is  reduced  to 
a  fluid  or  a  semi-fluid  mass,  walled  in  by  the  capsule  of  the  tumor, 
which  now  stands  in  the  relation  of  a  cyst  wall  to  the  disorganized 
contents. 

In  some  cases  the  softening  process  is  completed  without  extend- 
ing the  circumference  ;  the  ragged  processes  hanging  into  the  in- 
terior of  the  cavity  are  removed.  The  latter  acquire  a  smooth  lining, 
and  look  like  a  simple  cyst  lying  in  the  cavity  of  the  tumor. 

A  second  mode  in  which  softening  takes  place  is  more  rapid  and 
diff"used,  the  whole  or  the  greater  portion  of  the  tumor  being  affected 
at  once.  The  change  commences  with  the  infiltration  into  the  mass 
of  a  serous  fluid  whereby  its  texture  is  loosened  and  its  components 
separated,  at  the  same  time  the  tissue  of  the  tumor  is  softened,  and 
interstitial  absorption  is  set  up  in  it. 

As  the  result  of  these  processes  combined,  the  tumor  is  soon 
broken  up  into  detached  fragments,  and  reduced  to  a  diffluent  pulp, 
or  it  may  be  completely  liquefied.  These  changes.  Dr.  Humphrey 
suggests,  "are  occasioned  by  some  altered  nutrition  analogous  to  in- 
flammation; they  may  be  induced  by  some  accidental  cause,  as  an 
injury ;  nevertheless  they  are  not  necessarily  attended  with  any  con- 
stitutional disturbance  at  all  corresponding  with  the  extensive 
destruction  which  is  in  progress." 

Sujypuration. — This  is  very  rare;  it  may  commence  internally,  or 
progress  from  without  inward. 

Cancerous  Degeneration. — The  general  conditions  and  features 
of  such  degenerations  have  been  considered  in  the  body  of  the  chap- 
ter. It  remains,  however,  to  point  out  a  second  cancerous  relation, 
namely,  the  existence  of  compound  tumors.  Dr.  Lewis  relates  a 
case  where  melanotic  cancer  was  deposited  in  the  stroma  of  a  fibrous 
tumor,  and  Dr.  Humphrey  exhibited  a  large  fibrous  tumor  completely 


OSTEOSARCOMA. 


385 


enveloped  in  cancer.  In  such  cases  we  can  only  infer  the  fibrous 
tumor  to  have  existed  through  a  provocative  local  irritation,  while 
the  cancer  conjoined  with  it  is  a  separate  and  distinct  disease,  the 
result  of  cachexia. 

Fig.  81. — Osteo-Sarcomatous  Tumor. 


This  specimen,  from  the  person  of  an  old  woman,  commenced 
within  the  antrum,  and  progressed  four  years  before  causing  death. 
In  character  it  was  fibro-plastic,  with  here  and  there  osseous  masses. 

Fig.  82. — Cysto-Sarcoma. 


This  specimen  represents  a  case  just  operated  on  by  myself.  The 
reader  will,  from  the  text,  understand  it  without  any  special  descrip- 
tion.    The  patient  was  a  young  man  aged  about  thirty. 

25 


CHAPTER    XXVI. 


OSTEO-CARCINOMA. 


In  the  previous  chapter  various  tumors  were  referred  to,  differing, 
as  species  are  concerned,  agreeing  as  to  a  general  classification; 
these  various  species  being  grouped  under  the  common  class  term 
sarcoma. 

The  class  we  are  now  to  consider — the  heteroclitic — is  one  which 
has  been  equally  divided  and  subdivided,  specified  and  synonymed 
with  the  preceding, — so  much  so,  indeed,  as  to  elicit  from  most 
authors  a  confession  as  to  the  confusion  which  seems  to  render  any 
simple  and  exact  description  almost  impossible. 

Much  experience  has  suggested  to  my  mind  that  there  is  but  a 
single  cancerous  affection  of  the  jaws,  or  perhaps  I  will  be  better 
able  to  make  myself  understood  if  I  say  two  ;  all  peculiarities, 
modifications,  and  associations  are  but  pathological  features  de- 
veloped by  age  or  circumstances  in  the  one  or  the  other  of  these 
general  classes.  If  this  tenure  is  right,  when  I  describe  one,  or 
at  best  two  conditions,  with  their  associations,  1  shall,  for  all 
practical  purposes,  have  told  all  that  need  necessarily  be  known 
for  the  general  guidance  of  the  surgeon.     I  think  so,  at  least. 

Carcinoma  is  a  word  gotten  from  the  Greek  xapy.ivoq,  signifying  a 
crab.  According  to  the  classification  of  Fische,  which  it  suits  our 
purpose  to  adopt,  it  applies  to  a  family  of  diseases  which  embraces 
the  different  forms  of  cancer. 

Osteo-carcinoma  is  a  term,  then,  which  I  will  adopt  to  apply  to 
any  truly  cancerous  tumor  of  the  maxillary  bones ;  it  embraces  the 
two  species  which  I  have  said  are  the  only  malignant  growths  found 
associated  with  these  bones.  These  species  are  the  types  medullaris 
and  scirrhus. 

Scirrhus  of  the  maxillae  is  an  infrequent  condition — a  quite  rare 
disease.  Medullary  matter  is  the  pathological  feature  which  charac- 
terizes the  mass  of  the  carcinomatous  tumors  of  these  parts;  so 
constant,  indeed,  is  its  presence,  that  it  would  scarcely  be  amiss  to 
say  that  medullary  disease  is  the  only  cancer  of  the  jaws. 
(386) 


OSTEO-CARCINOMA.  387 

I  suppose  I  have,  in  the  course  of  my  observations,  met  with  two 
decided  cases  of  scirrhus  of  the  maxillary  bones,  both  being  associated 
with  the  superior  jaw  ;*  certainly  I  have  not  seen  more  than  these 
two  cases.  It  appears  first  as  a  hard  mass,  a  little  lump,  perhaps, 
associated  seemingly  with  the  overlying  soft  tissues,  movable  for 
a  time,  but  soon  becoming  fixed,  and  implicating  all  the  immediately 
surrounding  parts,  "casting  out  its  claws,"  as  the  people  have  it. 
If,  after  amputation,  a  scirrhous  mass  is  bisected,  it  is  found  to 
resemble  in  its  stroma  the  substance  of  a  turnip. 

The  hardness  of  scirrhus,  says  Mr.  Paget,  when  compared  with 
that  of  most  other  tumors,  is  extreme  ;  it  is  about  equal  to  that  of 
fibro-cartilage,  and  is  associated  with  a  corresponding  rigidity, 
weight,  and  inelasticity.  A  characteristic  appearance  is  a  slight 
concavity  assumed  by  these  tumors  on  section,  which  belong  to  no 
other  tumors.  It  differs  again  on  section  from  the  sarcomatous 
tumors  in  having  no  distinct  grain  or  fibrous  plan  of  arrangement. 

In  microscopic  structure  it  varies  still  more  markedly,  its  cells 
being  not  constant  but  heteroclitic.  Scirrhus,  like  medullary  cancer, 
tends,  but  much  more  slowly,  from  the  occult  to  the  open  stage. 

With  these  few  remarks  on  scirrhus,  which  will  serve  at  least  to 
exhibit  that  I  am  not  unaware  that  such  form  of  cancer  does  occa- 
sionally exist  in  the  jaws,  w^e  will  pass  to  the  medullary  form,  and 
which  I  will  now  assume  is  the  carcinoma  proper  and  peculiar  of 
the  parts. 

Miller  has,  however,  several  sections  on  malignant  scirrhus  of  the 
maxillary  bones,  which  he  considers  under  the  heads  osteo-cepha- 
loma,  osteo-carcinoma,  osteo-melanosis,  and  osteo-cancer.  Against 
these  subdivisions  I  shall  not  take  the  liberty  to  object,  leaving  it 
for  the  reader  to  judge  whether  they  are  not  but  one  and  the  same 
disease  with  modifications. 

Our  subject  can,  I  think,  be  divested  of  much  obscurity,  if  at  this 
point  we  stop  for  a  single  moment  to  consider  the  meaning  of  certain 
terms  which  long  usage  has  so  associated  with  cancerous  condi- 
tions that  they  must,  I  am  sure,  long  years  ago,  have  gotten  far  be- 
yond the  meaning  originally  intended  for  them.  Take  for  example 
the  term  fungus  hsematodes.  It  is  a  term  used  freely  and  loosely 
by  surgical  writers,  and  is  frequently  accepted  to  mean  most  malig- 
nant cancer.     Let  us  analyze  this  term  :  Ave  find  it  made  out  of  the 


*  Since  writing  the  above  I  have  met  with  scirrhus  proper  of  the  lower 
jaw. 


388  ORAL  DISEASES  AND  SURGERY. 

Greek  altm,  siffnifying  blood,  and  eiSoq,  meaning  appearance — of 
bloody  appearance.  Any  and  all  granulations  being  of  bloody  ap- 
pearance, are  therefore  fungi  haematodes.  If,  however,  it  was  meant 
to  be  applied  strictly  to  pathological  features,  we  might  employ 
it  learnedly  to  express  the  common  proud-flesh  of  any  adynamic 

ulcer. 

Writers  use  the  term  as  a  synonym  of  medullary  cancer,  but  when 
they  describe  fungus  haematodes,  they  get  a  condition  and  not  a  prin- 
ciple. They  might,  with  the  same  propriety,  use  the  word  suppura- 
tion as  a  synonym  of  inflammation.  Fungus  haematodes  is  a  phe- 
nomenon, as  suppuration  is  a  phenomenon,  as  pain  is  a  phenomenon 
attending  a  cause.  Such  looseness  in  describing  disease  cannot  but 
confuse  the  student  and  render  our  nomenclature  unreliable  as  a 
source  for  finding  expressive  terms;  terms  that  shall  be  patent  every- 
where, and  under  all  circumstances.  Thus  Mr.  Hey,  who  was  the 
originator  and  maker  of  the  term  fungus  haematodes,  employed  it 
as  the  representative  of  the  open  state  of  medullary  cancer ;  it  cer- 
tainly Avell  expresses  the  phenomenon,  but  has  no  more  special 
meaning. 

Alibert  calls  all  the  haematocies  by  this  same  name,  and  as  they 
are  all  of  bloody  appearance,  certainly  he  is  justified  in  so  expressing 
himself. 

Dupuytrcn  employs  the  term  in  describing  the  erectile  tumors, 
while  Graefe  presses  it  into  service  in  describing  the  "  Telangiecta- 
siae."  Thus,  as  a  first  example,  we  see  that  there  is  no  peculiar  dis- 
ease of  the  jaw  which  can  be  called  fungus  haematodes.  We  do  not, 
however,  eschew  the  term  ;  we  cannot  do  without  it,  as  it  represents 
a  feature. 

Let  us  take  a  second.  I  instanced  Miller's  fourth  classification  of 
cancer  of  the  maxillary  bones,  the  osteo-melanosis.  Now  the  term 
melanosis  refers  to  a  pigment,  and  signifies  simply  black  or  colored 
structure.  I  will  not  myself  say  that  Miller  errs  in  this  classifica- 
tion, but  will  simply  note  down  what  Mr.  Paget  says  concerning 
the  colored  cancers. 

"  The  melanotic  or  melanoid  cancers  are,"  says  Mr.  Paget, 
"according  to  my  experience,  with  very  rare  exceptions,  medullary 
cancers  modified  by  the  formation  of  black  pigment  in  their  ele- 
mental structures.  On  this  long  disputed  point  there  can,  I  think, 
be  no  reasonable  doubt.  I  have,"  he  says,  "  referred  to  a  case  of 
melanotic  epithelioma  [see  his  Lectures,  page  582],  but  with  this  ex- 
ception, I  have  not  seen  or  read  of  any  example  of  melanosis  or 


OSTEO-CARCINOMA.  389 

melanotic  tumor  in  the  human  being  which  might  not  be  regarded 
as  medullary  cancer  with  deposit  of  black  pigment." 

These  remarks  and  experiences  of  Mr.  Paget  exhibit  quite  satis- 
factorily, I  think,  the  fact  that  this  classification  is  an  unneces- 
sary, not  to  say  an  unscientifiic  one.  The  deposit  of  pigment  is 
not  the  disease,  but  merely  an  accidental  feature  appearing  in  its 
course. 

May  I  not,  then,  be  permitted  to  suggest  that  the  term,  in  the 
special  sense  in  which  it  is  employed  by  Mr.  Miller,  may  be  dropped 
without  detriment  to  nomenclature  ? 

The  osteo-cephaloma  of  Miller  is  medullary  cancer. 

Osteo-carcinoma  ;  I  have  given  the  derivation  of  this  term,  and 
exhibited  its  character  as  a  noun  of  multitude. 

Miller,  in  his  classification,  thus  writes  :  "  Osteo-carcinoma  is  com- 
paratively rare  ;  when  it  does  occur  it  is  usually  as  a  secondary 
symptom  of  malignant  cachexia,  the  primary  indication  of  which 
has  been  the  formation  of  carcinoma  in  the  soft  parts." 

If,  in  this  classification.  Miller  is  compared  with  other  authors,  his 
meaning  will  be  difficult  to  make  out.  If  he  had  not  so  specially 
classified  the  disease,  I  would  suppose  he  meant  the  same  as  Fische  ; 
but  osteo-carcinoma,  as  Fische  emplo3'S  the  term,  and  as  we  here  fol- 
low him,  is  not  a  very  rare  condition  ;  on  the  contrary,  it  is  unfor- 
tunately a  quite  common  disease.  I  would  ask,  then,  considering 
the  character  of  the  term  carcinoma  as  a  noun  of  multitude,  if  this 
classification  of  Miller  might  not  also  be  dispensed  with  ? 

Osteo-Gancer. — This  is  another  classification  ;  it  is  used  as  a  sign 
of  the  malignant  ulceration  of  bone.  The  only  objection  to  be 
urged  against  the  term  is,  that  it  makes  another  unnecessary  class. 
We  would  scarcely  suppose  that  an  ulceration  could  occur  as  the 
primary  lesion.  If,  then,  it  is  a  secondary  condition,  it  is  only  an 
attendant  phenomenon,  and  can  have  no  claim  to  the  distinction  of 
special  classification — the  disease,  or  rather  the  condition,  would  be 
carcinoma  in  a  state  of  ulceration,  and  it  seems  to  me,  if  we  should 
describe  it  as  ulcerating  osteo-carcinoma,  we  would  give  it  all  proper 
signification,  while,  at  the  same  time,  we  should  make  still  one  less 
of  these  special  confusions. 

Synonyms. — To  these,  when  learnedly  made,  no  objections  can 
perhaps,  be  urged.  So  many  names  for  one  thing  is,  without  doubt, 
confusing  enough  to  the  student ;  but  then,  this  is  a  matter  which 
time  and  study  make  familiar  to  him,  and  more  than  this,  reason- 
able and  proper. 


390  ORAL  DISEASES  AND   SURGERY. 

I  would  have  my  reader,  then,  infer  that  if,  in  the  study  of  the 
malignant  disease  of  the  jaws,  he  will  agree  to  throw  entirely  aside 
the  unjust  nomenclature  which  so  surrounds  the  subject,  and  ap- 
l)roach  the  study  on  general  principles  alone,  he  may,  from  a  single 
stand-point,  at  a  single  glance,  take  in  the  whole  of  the  subject. 

And  first,  to  return  to  what  has  been  alluded  to  as  the  persistent 

tvpe medullary  matter.    This  form  of  carcinoma  is  named  from  its 

resemblance  to  brain  substance.  Its  synonyms  are  many,  generally 
good,  but  a  little  confusing  when  associated  with  degenerating  sar- 
coma; but  on  this  point  I  hope  the  student  is  sufficiently  fortified. 

I  have  remarked  that  one  classification  made  by  Miller,  of  the 
cancerous  tumors  of  the  jaws,  is  osteo-cephaloma :  this  is  a  syno- 
nym of  medullary;  the  only  form  of  cancer  of  the  maxillary  bones, 
with  the  exception  mentioned.  Now  in  Mr.  Miller's  book  is  a  com- 
parison which  he  has  drawn  between  osteo-sarcoma  and  osteo- 
cephaloma;  the  comparison  embraces  ten  conditions.  If  the  reader 
will  closely  study  them  he  will  truly  have  his  subject  in  a  nutshell. 

1.  Says  Mr.  Miller:  Osteo-sarcoma  is  seldom  found  prior  to  adult 
age;  osteo-cephaloma  may  occur  at  any  period,  and  is  as  frequent  in 
the  adolescent  as  in  the  adult. 

2.  Osteo-sarcoma  is  usually  attributable  in  its  origin  to  external 
injury.     Osteo-cephaloma  is  most  frequently  of  spontaneous  origin. 

3.  Osteo-sarcoma  is  slow  and  gradual,  and  more  or  less  uniform 
in  its  growth.  Osteo-cephaloma  is  much  more  rapid,  and  tends  to 
enlarge  unequally,  growing  chiefly  at  those  points  where  there  is 
least  mechanical  resistance. 

4.  Osteo-sarcoma  is  usually  almost,  and  sometimes  altogether, 
painless,  unless  when  some  nervous  trunk  or  plexus  is  compressed. 
Osteo-cephaloma,  from  the  first,  is  attended  with  severe  lancinating 
pains. 

5.  Osteo-sarcoma  is  firm,  and  yields  but  little  to  touch,  even  undue 
pressure  is  scarcely  painful ;  and  obscure  crepitus  is  often  felt. 
Osteo-cephaloma  is  soft  and  elastic  from  an  early  period;  the  shell 
of  bone  and  all  other  original  texture  soon  becoming  merged  in  the 
medullary  formation.  It  is  elastic,  and  affords  no  crepitus  when  an 
original  tumor,  and  pain  is  aggravated  by  compression. 

6.  Osteo-sarcoma  entails  but  little  disorder  of  the  general  health. 
Osteo-cephaloma  is  attended  by  marked  cachexia,  even  from  the  be- 
ginning. 

7.  A  casual  abrasion  of  the  skin,  or  mucous  membrane  investing 
an  osteo-sarcoma,  shows  a  simple  character,  and  may  be  brought  to 


OSTEO-CARCINOMA.  391 

heal  under  ortHnary  treatment.  A  similar  breach  in  the  surface  of 
an  osteo-cephaloma  does  not  heal,  but  widens  more  and  more  and 
becomes  the  site  of  fungous  protrusions. 

8.  Osteo-sarcoma  does  not  invade  the  neighboring  tissues,  but 
pushes  them  aside  by  its  expansion,  and  abides  within  the  bone  in 
which  it  was  developed.  In  the  upper  jaw,  for  example,  it  remains 
limited  to  the  expanded  confines  of  the  antrum,  and  at  those  points 
where  the  bony  and  even  membranous  parietes  are  deficient,  there 
is  no  ulceration  followed  by  fungous  protrusions,  but  only  a  mode- 
rate increase  of  growth  in  a  lobulated  form,  with  or  without  a  raw- 
ness of  the  surface.  Osteo-cephaloma,  on  the  other  hand,  pushes 
no  texture  much  aside,  but  early  involves  all;  the  antrum  is  soon 
passed  beyond,  and  the  base  of  the  cranium  is  affected  even  before 
much  show  has  been  made  externally.  Whenever  deficiency  of  the 
investing  texture  occiu"s,  ulceration  and  fungous  growths  are  sure  to 
follow. 

9.  Osteo-sarcoma  long  continues  in  the  occult  condition.  Breach 
of  the  surface,  when  it  does  occur,  does  not  extend  rapidly,  and 
evinces  no  tendency  to  malignity  of  character.  The  discharge  is 
purulent  or  puriform,  not  profuse.  There  is  no  tendency  to  hemor- 
rhage unless  by  accidental  injury,  and  then  it  is  slight,  and  easily 
controlled  by  pressure.  Osteo-cephaloma  soon  passes  from  the  oc- 
cult to  the  open  stage.  The  ulcer  spreads,  and  is  obviously  the 
seat  of  malignancy.  Discharge  is  profuse,  fetid,  and  bloody.  Hem- 
orrhage is  not  unlikely,  of  spontaneous  origin,  and  little  amenable 
to  control. 

10.  Osteo-sarcoma  does  not  spread,  either  by  contiguity  in  the 
tissue,  or  remotely  by  the  lymphatics.  Osteo-cephaloma  does  both; 
at  an  early  period  the  lymphatics  are  manifestly  and  hopelessly  in- 
volved. 

These  comparisons  by  Mr.  Miller  are  very  happy.  The  reader 
must  not  forget,  however,  the  tendency  of  sarcoma  to  pass  into  car- 
cinoma, and  that  there  is,  very  frequently,  a  period  in  the  history  of 
the  former  in  which  it  is  almost  impossible  to  say  whether  the  simple 
or  malignant  structure  predominates.  The  comparisons  refer  to 
marked  conditions  in  the  two  diseases, — that  is,  true  and  unmixed 
osteo-sarcoma  and  decided  osteo-carcinoma  or  cephaloma. 

Practically,  says  Mr.  Miller,  it  is  of  the  utmost  importance  that 
we  should  be  able  to  distinguish  between  the  two  diseases:  each  is 
of  not  unfrequent  occurrence,  and  each  requires  distinct  rules  of 
treatment. 


392  ORAL   DISEASES  AND  SURGERY. 

Osteo-sarcoma  admits  of  operation  to  a  late  period  ;  its  extirpation 
may  be  fearlessly  attempted  with  a  good  hope  of  success  even  after 
the  tumor  has  an  enormous  bulk,  and  experience  has  shown  that  the 
operation,  though  it  may  be  bloody  and  severe,  yet  seldom  termin- 
ates but  in  a  fortunate  issue. 

Osteo-carcinomatous  tumors  are,  on  the  contrary, — I  would  speak 
my  own  experience  if  I  were  to  say, — not  at  all  amenable  to  treat- 
ment of  any  kind.  Miller  thought  they  might  be  operated  on  at  an 
early  period  successfully,  but  I  must  say  (and  clinically  I  have  seen 
a  great  deal  of  this  disease)  I  never  saw  one  cured.  This  assertion 
implies,  however,  that  the  diagnosis  has  been  correct;  there  are 
so-called  medullary  cancers  cured  every  day.  Cancerous  deposits 
seem  so  evidently  the  work  of  systemic  conditions  that  when  you 
remove  a  part  containing  the  localized  disease,  you  seem  but  to  have 
exposed  the  conduits  which  are  engaged  in  bringing  to  the  bulk 
fresh  material :  you  cannot  get  beyond  the  disease  with  your  knife ; 
all  adjoining  parts  are  more  or  less  infiltrated  with  the  materise 
raorbis. 

"I  entirely  differ,"  says  Mr.  Hancock,  "from  Mr.  Stanly  and  Mr. 
Liston,  that  medullary  carcinoma  commences  in  the  antrum  of  High- 
more  and  extends  backward  to  the  pterygoid  process ;  but,  on  the 
contrary,  from  what  I  have  observed,  I  firmly  believe  that  the  dis- 
ease commences  in  the  cancellated  structure  of  the  body  of  the 
sphenoid  bone  and  bones  at  the  base  of  the  cranium,  and  that,  how- 
ever early  we  may  perform  the  operation,  we  never  succeed  in  eradi- 
cating the  mischief,  which  is  sure  to  return  at  a  longer  or  shorter 
period,  according  to  circumstances." 

It  strikes  me  that  if  Mr.  Hancock  had  only  for  one  moment  con- 
sidered the  constitutional  relations  of  cancer,  he  need  not  have  found 
himself  in  dispute  with  his  illustrious  peers.  For  my  own  part,  I 
know  that  medullary  disease  does  begin  in  the  maxillary  sinus,  for 
I  have  over  and  again  seen  such  cases,  and  so  also  may  it  begin,  as 
location  is  concerned,  almost  anywhere  else  about  the  body;  the 
tumor  is  not  the  disease,  but  only  the  local  expression  of  it. 

But  however  this  may  be,  I  quoted  Mr.  Hancock's  expression  only 
as  it  is  indicative  of  a  general  experience  of  the  difficulty  of  getting 
away  by  operation  even  all  of  what  is  apparently  the  local  disease; 
and  how  could  it  be  otherwise,  seeing  the  tumor  is  not  encysted, 
being  rather  an  infiltration,  as  it  were  ? 

What  then  is  to  be  done  in  this  condition  ?  I  can  only  answer, 
let  every  man  use  his  best  judgment.     We  know  the  history  of  the 


OSTEO-CARCINOMA.  393 

disease :  that  it  tends  to  fungoid  conditions,  that  it  becomes  so  offen- 
sive as  to  make  the  patient  not  only  disagreeable  to  his  friends  but 
also  to  himself,  that  it  is  associated  with  most  unbearable  pain, 
etc.  We  may  feel  ourselves  justified  in  operating  for  a  twofold 
reason:  first,  that  we  may  give  to  the  patient  temporary  relief; 
second,  with  the  hope  that  the  reappearance  may  be  in  some  in- 
ternal situation,  rather  than  the  site  of  removal ;  thus  at  least  put- 
ting out  of  sight  a  disgusting  mass  which  it  can  be  of  little  use  to 
have  under  manipulative  control. 

There  are,  however,  the  following  general  indications  which 
should  always  be  taken  into  consideration,  and  which,  being  met, 
may  possibly  result  in  good  to  the  patient : 

1st.  As  the  disease  is  due  to  or  accompanied  by  perverted  nutri- 
tion, every  effort  should  be  made  to  remove  any  derangement  in  the 
nutritive  organs,  while  the  general  health  should  be  cared  for  thi'ough 
the  generous  use  of  rich  diet,  tonics,  and  alteratives. 

2d.  To  remove  or  check  local  irritation. 

3d.  To  continue  the  constitutional  treatment  through  all  stages 
of  the  disease,  not  neglecting  the  quieting  assistance  of  the  opiates. 

4th.  To  operate  early,  if  at  all,  provided  the  disease  presents  such 
conditions  as  to  warrant  interference. 

5th.  To  select  such  means  for  its  removal  as  will  be  likely  to  pro- 
duce the  least  irritation. 

Professor  Smith  thinks  the  greatest  amount  of  good  is  to  be  got- 
ten from  the  chalybeates.  He  recommend's  Vallet's  mass  in  do.ses 
of  from  five  to  ten  grains  three  times  a  day.  In  one  case,  he  says, 
in  which  he  was  consulted  with  a  view  to  operating,  and  declined 
on  account  of  the  rapid  progress  of  the  disease,  he  suggested  the 
use  of  Vallet's  mass  conjoined  with  the  application  of  the  powdered 
carbonate  to  the  sore,  and  the  patient  lived  for  eight  years  without 
the  disease  having  made  any  very  great  progress.  Justamond,  of 
London,  says  Dr.  Smith,  gave  from  sixty  to  one  hundred  and  twenty 
grains  of  the  ammonio-chloride  per  diem  ;  while  Carmichael,  of  Dub- 
lin, expresses  himself  as  having  derived  much  benefit  from  washing 
ulcerated  scirrhus  with  a  solution  of  sulphate  of  iron. 

Chloride  of  zinc  and  solutions  of  the  salt  are  favorite  preparations. 
I  believe,  from  what  I  have  seen,  that  if  it  were  possible  to  cure  a 
cancer  by  local  means,  chloride  of  zinc  would  prove  the  most  for- 
midable antagonist  we  could  bring  to  bear  against  it.  Its  power 
to  arrest  phagedenic  action  is  wonderful.  The  medicine  has  more 
than  a  cauterant  property:  it  is  peculiarly  alterative.     Judiciously 


394  ORAL  DISEASES  AXD   SURGERY. 

applied  to  any  indolent,  irritable,  or  bad  ulcer,  it  will  be  found  to 
tend  markedly  to  a  change  for  the  better. 

Concerning  the  use  of  this  agent  in  cancer,  vre  have  many  com- 
mendations, particularly  from  European  surgeons;  but,  as  can  be 
very  readily  apprehended,  nowhere  in  the  range  of  its  application 
is  more  judgment  required  for  its  proper  employment  than  here,  for 
it  is  a  cauterant,  a  stimulant,  an  antiseptic,  and  alterative.  Dr. 
Zuerine,  of  Vienna,  relates  a  case  of  cancerous  ulceration  of  the 
septum  nasi  which  threatened  to  destroy  the  whole  nose  ;  one  grain 
and  a  half  of  the  chloride  of  zinc,  he  says,  were  dissolved  in  one 
ounce  of  distilled  water,  and  the  scabs  being  removed,  the  sore  was 
penciled  over  several  times  a  day  with  the  solution ;  at  the  end  of  a 
fortnight  a  healthy  granulating  surface  was  found  underneath  the 
thick  crust  which  covered  the  sore,  and  this  being  occasionally  re- 
moved, and  the  solution  reapplied,  it  cicatrized  in  five  weeks. 

Mr.  Tuson  has  published  some  cases  to  show  the  value  of  cer- 
tain preparations  of  chlorine  in  cancerous  affections.  In  one  which 
he  publishes  there  was  an  extensive  cancerous  aflTection  of  the  right 
breast  and  neck,  which  was  treated  unsuccessfully  for  a  long  time, 
till  a  paste  was  applied,  made  of  one  part  of  chloride  of  zinc  to  three 
of  flour ;  this  was  well  mixed,  and  moistened  with  water,  and  then 
applied  over  the  ulcerated  parts.  The  zinc  was  also  given  internally ; 
half  a  grain  was  ordered  in  a  wineglassful  of  caraway-water  every 
morning.  The  chloride  of  zinc  paste  was  applied  again,  and  when 
the  slough  separated,  the  ulcerated  surface  healed  kindly.  The  can- 
cerous deposition  continued  for  some  time,  and  the  dose  of  the  metal 
was  increased  to  three-quarters  of  a  grain  and  continued  for  three 
months.  The  improvement,  although  very  striking,  was  not  per- 
manent, as  the  patient  suffered  a  relapse  which  ended  fatally.  The 
case,  however,  was  sufficient  to  show  that  the  treatment  had  made 
considerable  impression  on  the  disease,  and  especially  in  healing 
the  open  cancer,  which  Mr.  Tuson  had  found  to  be  the  result  in 
several  other  cases. 

The  great  suffering  associated  with  carcinoma  makes  necessary 
the  free  use  of  opiates,  both  locally  and  internally.  Stramonium, 
belladonna,  aconite,  opium  and  its  preparations,  hamamelis,  are 
highly  recommended.  As  much  as  twenty  grains  of  sulphate  of 
morphia  have  been  administered  during  the  course  of  a  single 
twenty-four  hours.  Injections  by  the  subcutaneous  method,  where 
morphia  is  to  be  long  continued,  are  now  generally  resorted  to.  Bat- 
ley's  solution  answers  best  for  this  manner  of  use. 


CHAPTER    XXVII. 


EPITHELIOMA. 


In  connection  with  the  carcinomatous  tumors  of  the  mouth,  it 
may  not  be  out  of  place  to  refer  to  the  affection,  not  uncommon  in 
the  oral  cavity,  known  as  epithelioma.  This  is  a  disease  commenc- 
ing frequently  as  a  superficial  ulceration  either  upon  the  gums  or 
mucous  membrane  of  the  cheek,  and  implicating  by  extension  the 
underlying  osseous  structure.  When  first  observed,  the  ulcer  may 
not  be  larger  than  two  or  three  lines,  yet  even  so  small,  may  be  dis- 
tinguished by  the  sore  being  ragged  and  irregular.  If  seated  upon 
the  gum,  examination  with  a  delicate  and  pointed  probe  will  reveal 
caries  of  the  bone  already  in  progress.  When  a  diagnosis  is  doubt- 
ful, a  few  days  of  ordinary  treatment  will  discover,  by  its  uselessness, 
the  intractable  nature  of  the  trouble,  and  set  at  rest  any  doubts. 

Epithelioma  as  situated  upon  the  lower  lip  is  familiar  to  every 
one;  here  seems  to  be  its  favorite  seat.  Commencing  as  a  slight 
fissure,  it  runs  on  to  the  speedy  destruction  of  the  patient,  involving 
in  a  very  short  time  the  whole  lip  and  surrounding  parts,  or,  as  in 
less  malignant  cases,  circumscribes  itself  in  the  form  of  an  indurated 
mass,  remaining  for  a  long  time,  gathering  force,  as  it  were,  for  a  final 
onslaught. 

Epithelioma  is  cancer,  but  it  differs  from  medullary,  as  fatality  is 
concerned,  in  seeming  to  have  primarily  but  a  local  signification — 
at  least  so  it  seems  to  me :  left  to  itself,  it  will  certainly  destroy  the 
life  of  one  affected  with  it ;  taken  in  time,  I  am  confident  it  may  be 
cured.  Let  me  qualify,  however:  safety  through  early  operation 
may  exist  only  in  the  less  marked  form  of  the  disease.  That  I  have 
cured  epithelioma  by  operations,  I  have  surviving  patients  to  show. 
That  they  have  died  after  operations  quite  as  carefully  and  judi- 
ciously performed,  the  grave,  I  am  sorry  to  say,  holds  examples 
from  me. 

When  commencing  in  the  skin,  epithelioma  is  apt  to  present  itself 
in  the  warty  or  indurated  form ;  on  clean  mucous  membrane,  as  an 
ulcer.     Situated  upon  the  lip  or  anus,  having  thereby  associations 

(395) 


396  ORAL  DISEASES  AND   SURGERY. 

with  both  skin  and  mucous  membrane,  it  may  present  itself  in  either 
form,  or  even  pedunculated.  When  indurated,  the  virus  of  the  dis- 
ease seems  circumscribed  ;  when  ulcerated,  it  appears  to  be  more  or 
less  infiltrated  through  the  adjoining  tissues.  This  relationship  of 
the  virus  in  the  two  conditions  would  seem  to  be  proven  by  the  rela- 
tive success  of  operations  performed  upon  them  ;  the  indurated,  par- 
ticularlv  the  warty,  being  always  the  most  amenable  to  treatment. 
It  is  generally  understood  that  the  edge.^  of  an  epithelial  ulcer  are 
hard  and  indurated,  but  this  is  not  always  the  case,  as  my  own  expe- 
rience has  exhibited  to  me.  Indeed,  such  ulcers  are  very  much  like 
chancres,  hard  and  soft,  and  would  be  exactly  like  them  were  it  not 
for  the  dilference  in  the  bottoms  of  the  sore,  the  one  being  pasty, 
the  other  fungous. 

The  relative  frequency  of  epithelioma  situated  inside  the  vestibule 
compared  with  that  upon  the  lip,  its  favorite  seat,  is  about  as  three 
to  twelve.  The  relative  danger  of  positions  may  be  reversed.  Situ- 
ated within  the  mouth,  operative  interference  cannot  be  practiced 
at  too  early  a  period ;  in  other  situations,  circumstances  may  ex- 
cuse delays.  Operations,  to  promise  any  hopes  of  success,  must  be 
thorough  ;  it  is  not  enough  to  remove  the  apparent  disease,  the 
more  of  neighboring  parts  embraced  in  the  incisions  the  better. 
Complete  excision,  when  it  can  safely  be  practiced,  is  always  the 
preferable  treatment. 

Two  cases,  directly  opposite  in  character  and  result,  will  serve  as 
instructive  illustrations. 

Mr.  N.,  carpenter  by  occupation,  was  sent  to  me  laboring  under  an 
indurated  tumefaction  involving  a  full  half  of  the  inferior  lip :  the 
tumor  was  semi-bluish,  slightly  lobulated  and  painful,  had  existed 
for  over  a  year,  was  gradually  enlarging  and  softening.  The  diag- 
nosis of  epithelioma  but  verified  the  opinion  of  several  other  practi- 
tioners who  from  time  to  time  had  examined  it.  Recommended  the  re- 
moval of  the  whole  lip,  which  was  concurred  in  by  the  patient.  The 
gap,  which  was  made  in  the  ordinary  V  shape,  great  as  it  was, 
being  carried  from  either  angle  of  the  mouth  to  the  symphysis 
menti,  was  filled  up  without  any  considerable  effort  by  forcing  the 
cheeks  toward  the  mesial  line,  retaining  them  in  position  by  an 
extemporized  Dewar's  compressor,  and  approximating  the  edges  of 
the  wound  with  the  hare-lip  pin  and  suture.  The  wound  united 
happily  by  first  intention  throughout,  and  although  at  first  the 
stretched  tissues  bound  the  lower  jaw  so  closely  as  almost  to  pre- 
vent the  patient  opening  the  mouth,  yet  at  this  date,  and  indeed 


EPITHELIOMA. 


397 


in  three  months  after  the  operation,  so  completely  had  the  parts 
accommodated  themselves  to  the  new  condition  of  things  that  one 
would  almost  fail  to  detect  that  the  natural  parts  had  ever  been 
interfered  with.  The  success  of  the  treatment  has  been  all  that 
could  be  desired ;  nearly  three  years  have  passed,  and  there  is  not 
the  slightest  evidence  of  a  return  of  the  trouble. 

Tig.  83.— View  of  Cask. 


Case  II. — EpitheJioma  of  Gum. — M.  G.,  aged  about  twenty-one, 
farmer  by  occupation,  was  sent  to  me  about  two  years  back  by  Dr. 
Edward  Townsend,  whose  dental  patient  he  was.  Dr.  T.,  while 
treating  a  bicuspid  tooth,  remarked  at  the  neck  a  slight  ulceration, 
but  which  appearing  of  little  consequence,  scarcely  at  the  time  com- 
manded more  than  a  passing  thought.  Attempting,  however,  at  a 
later  period  its  cure,  its  obstinacy  in  yielding  excited  his  suspicions, 
and  being  unwilling  to  assume  the  trouble  of  the  case,  he  directed 
the  patient  to  my  care.  Examination  made  on  first  meeting  the 
patient  revealed  a  small  ulcer  on  the  left  superior  gum  between  the 
bicuspid  teeth,  in  size  about  half  as  large  as  the  silver  three-cent 
piece,  jagged,  covered  with  a  whitish  gummy  secretion,  and  ap- 
parently superficial.  The  passage  of  a  sharp  probe  through  the 
center  of  the  ulcer  revealed  the  characteristic  carious,  softened,  and 
periosteally  denuded  bone.  Satisfied  in  my  own  mind  of  the  char- 
acter of  the  ulceration,  yet  unwilling  while  there  might  be  an  unre- 
futed  doubt,  however  slight,  to  depress  the  patient  by  informing 
him  of  the  nature  of  his  disease,  I  placed  him  under  ordinary  treat- 
ment for  a  period  of  two  weeks,  at  the  end  of  which  time,  finding 
my  experience  agree  with  Dr.  Townsend,  I  laid  before  him  his  con- 
dition, advising  an  immediate  resection  of  the  affected  and  adjoining 
parts.  Unwilling  to  submit,  the  patient  desired  consultation,  and  in 
turn  the  advice  of  every  prominent  surgeon  in  the  city  was  obtained. 
Opinions  differing,  he,  by  my  advice,  submitted  himself  to  various 
proposed  remedies,  being  treated  two  weeks  by  one  gentleman,  eight 


398  ORAL  DISEASES  A\W   SURGERY. 

weeks  by  a  second,  and  nine  by  a  third,  the  disease  progressing,  but 
slowly,  all  these  weeks.  At  the  end  of  this  time  I  again  proposed 
and  insisted  upon  an  operation,  informing  the  patient  of  the  neces- 
sarily increased  magnitude  of  the  portion  of  bone  and  soft  parts  to 
be  removed  •  still  refusing,  I  declined  to  take  further  responsibility 
in  the  case.  The  patient  making  me  a  visit  at  a  later  period,  I  found 
the  ulceration  involving  the  Stenonian  duct,  and  extending  from  the 
symphyses  to  the  tuberosity  of  the  bone.  At  this  visit  I  informed 
him  of  the  utter  hopelessness  of  any  operation  for  his  relief,  the  dis- 
ease being  too  extensive  From  this  time  to  that  of  his  death,  which 
happened  in  a  few  months,  he  was  in  the  hands  of  different  adver- 
tising impostors,  and  of  the  treatment  pursued  I  know,  and  desire  to 
know,  nothing.  Whether  or  not  an  early  operation  would  have  saved 
this  patient  from  his  early  death  I  may  not  of  a  certainty  say,  but 
from  a  rea»sonable  experience  in  the  direction  I  may  assert  that  with- 
out the  performance  of  such  proposed  operation  he  had  no  possible 

chance. 

Fig.  84. — View  of  Case  as  first  seek. 


Case  III. — Col.  W.,  merchant.  Epithelioma  involving,  when  first 
seen  by  me,  lip,  tongue,  and  cheeks — case  hopeless.  The  disease  in 
this  patient  began  as  a  minute  tubercle  just  over  the  genial  bodies 
of  the  inferior  maxilla ;  thought  little  about  it,  only  received  atten- 
tion when  found  ulcerating,  such  attention,  from  misappreciation  of 
its  character,  consisting  in  the  too  common  application  of  caustics. 
Aggravated  by  such  treatment,  the  ulceration  commenced  rapidly  to 
spread,  defying,  when  too  late  understood,  every  means  employed 
for  its  arrest.  Shortly  after  coming  under  my  care,  the  lip  fell  off  in 
mass,  the  root  of  the  tongue  indurated  to  such  an  extent  as  to  inter- 
fere with  both  respiration  and  deglutition,  and  the  patient,  a  fine 
robust  man,  died  from  prostration. 


EPITHELIOMA. 


399 


It  must  be  clearly  seen  that  whatever  chance  existed  for  this 
patient,  it  lay  not  in  exciting  and  aggravating  by  caustics,  but  in 
the  complete  removal  of  the  primary  tubercle  with  all  the  immedi- 

FiG.  85. — View  of  Case. 


ately  adjacent  tissues.  That  error,  if  error  there  be,  shall  be  on  the 
safe  side,  I  make  it  a  rule  always  to  cut  away,  with  a  large  margin, 
such  tubercles :  if  they  are  benign,  little  harm  has  been  done ;  if 
they  are  malignant,  the  free  removal  has  perhaps  saved  a  life. 

Epithelioma  when  involving  only  a  part  of  the  tongue,  and  when 
markedly  circumscribed,  may  be  operated  on  with  a  warrantable  de- 
gree of  success  ;  it  is  better  in  these  cases,  particularly  if  the  indura- 
tion is  at  all  extensive,  to  amputate  all  that  portion  of  the  organ  in 
mass  associated  with  the  disease ;  for  this  purpose  no  better  instru- 
ment can  be  employed  than  the  ecraseur  of  Chassaignac  ;  no  hemor- 
rhage attends  the  operation,  and  if  the  system  has  been  properly 
prepared,  the  subsequent  inflammation  is  not  of  any  considerable 
importance.  When,  however,  not  only  the  tongue  but  neighboi'ing 
parts  are  involved,  any  operation  promises  very  little, — one  ulcer  or 
tumor  may  be  managed,  two  seldom  or  never.  (See  Diseases  of 
Tongue.) 

The  term  epithelioma  is  not,  however,  to  be  received  as  neces- 
sarily equivalent  to  a  dangerous  disease.  In  the  work  of  Professor 
Henry  H.  Smith,  on  Surgery,  occur  the  following  passages  on  this 
subject,  which  can  only  be  read  by  the  student  to  his  profound  ad- 
vantage : 

"  When  from  any  cause  irritation  is  developed  in  the  skin,  its  ap- 
pendages, or  in  the  mucous  membranes,  the  normal  action  that  daily 


400  ORAL  DISEASES  AND  SURGERY. 

casts  off  dead  epithelial  cells  is  increased,  and  may  be  followed  by 
hypertrophy,  or  by  such  thickening,  degeneration,  and  ulcerative 
action  as  will  materially  modify  the  normal  condition.  Tumors  thus 
formed  on  the  skin  and  mucous  membrane  by  the  accumulation  of  a 
largely  increased  number  of  epidermic  and  epithelial  cells,  united 
together  by  filaments  of  fibrous  tissue,  and  furnished  with  blood- 
vessels, as  the  result  of  the  organization  of  the  fibrinous  deposit, 
have  been  called,  by  Hannover,  Epithelioma. 

"  Epithelioma  vary  considerably  in  appearance.  If  the  result  of 
the  irritation  caused  by  pressure  on  the  skin,  they  constitute  Corns 
of  common  language,  and  are  a  true  hypertrophy  of  the  epidermis. 
When  the  epidermic  cells  are  closely  packed  together  by  pressure, 
they  create  Hard  corns ;  when  the  cells  are  more  distinct  and  dis- 
posed to  a  papillary  arrangement,  owing  to  the  presence  of  a  greater 
amount  of  moisture,  they  form  Soft  corns. 

"When  the  epidermic  cells  accumulate  upon  a  surface  in  conse- 
quence of  the  increased  action  that  follows  a  local  congestion  or 
simple  redness,  they  form  the  varieties  of  skin  disease  known  as  the 
Squamae  or  Scaly  Class,  as  Psoriasis.  Condylomata  and  Venereal 
warts  are  analogous  tumors,  usually  found  on  the  points  where  the 
skin  and  mucous  membranes  blend,  as  the  corona  glandis  of  the 
penis,  the  vulva,  and  anus,  or  about  the  lips  and  nostril.  Both 
venereal  warts  and  condylomata  are  developed  apparently  in  some 
instances  in  consequence  of  a  peculiar  contamination,  as  has  been 
described  under  the  head  of  secondary  syphilis.  When  closely  ex- 
amined, condylomata  are  found  to  be  formed  of  a  congeries  of  papillae, 
sometimes  flattened  on  the  top,  while  others  have  fissures  that  lead 
down  to  a  common  stalk.  When  small,  condylomata  are  mostly 
composed  of  epithelial  scales,  but  in  the  larger  growths  there  is 
more  or  less  areolar  tissue  supplied  with  small  blood-vessels.  A 
vertical  section  exhibits  a  vascular  loop  surrounded  by  a  basement 
membrane,  external  to  which  are  layers  of  epithelial  cells  that  vary 
in  thickness.*  Common  skin  Warts,  as  often  seen  on  the  hands, 
belong  strictly  to  the  class  of  epithelioma,  being  formed  of  epithelial 
cells  not  compressed,  and  of  a  papillary  form.  These  are  mainly 
the  result  of  some  local  irritant  that  increases,  on  a  circumscribed 
spot,  the  epidermic  cell  action.  All  these  tumors,  when  inflamed, 
may  undergo  fatty  degeneration,  softening,  and  ulceration,  creating 
ichorous  and  irritating  discharges,  and  sympathetic  irritation  of  ad- 

*  Bennett's  Lectures. 


EPITHELIOMA.  401 

jacent  lymphatic  glands,  those  of  the  groin  occasionally  enlarging 
from  irritated  corns  on  the  toes,  and  those  of  the  axilla  from  inflamed 
warts  on  the  fingers. 

"  The  greater  vascularity  of  mucous  membranes  modifies  the  forma- 
tion of  epithelioma  in  this  tissue,  the  induration  or  small  scaly  wart 
degenerating  and  ulcerating,  and  creating,  through  inflammatory 
action,  more  or  less  induration  of  the  parts  immediately  adjacent. 

"  When  any  irritation  develops  this  action  on  a  mucous  membrane 
or  where  raucous  tissue  and  skin  blend,  it  is  apt  to  create  an  ulcer- 
ated epithelioma  that  is  difficult  to  heal.  This  variety  is  found  on 
the  margin  of  the  lip,  in  the  aire  of  the  nostril,  in  the  inner  canthus 
of  the  eye,  after  fissure  of  the  nipple,  on  the  tip  and  margin  of  the 
tongue,  on  the  os  uteri,  as  well  as  on  the  vulva,  prepuce,  and  anus. 
The  rodent  skin  ulcer  of  the  scrotum,  and  lupus  are  also  assigned  to 
this  same  class  of  growths.  When  in  these  localities  epithelioma 
is  developed,  it  commences  as  a  flattened  induration  or  scale,  which 
is  followed  by  a  slight  crack  or  fissure,  and  an  ichorous  watery  ex- 
udation that  is  irritating.  Hence  increased  action,  then  ulceration, 
with  induration  of  the  margin,  so  as  to  give  an  apparent  depth  to 
the  ulcer,  which  is,  in  reality,  quite  superficial.  The  pus  from  this 
ulcer  being  small  in  quantity,  soon  dries  and  forms  a  scab  or  scale, 
which,  being  accidentally  removed,  is  followed  by  slight  bleeding  and 
another  crust,  the  reproduction  being  in  this  manner  continued  for 
months.  When  these  ulcers  are  examined  microscopically  they 
present  on  the  surface  masses  of  epithelial  cells  in  all  stages  of  de- 
velopment. The  lymphatic  glands  near  these  ulcers  often  enlarge, 
and  are  secondarily  affected,  in  consequence  of  which  many  writers 
regard  this  variety  of  epithelioma  as  analogous  to  cancer.  That 
epithelioma  may  assume  the  cancerous  peculiarities  under  some  cir- 
cumstances, is  beyond  question ;  but  it  is  equally  certain  that  it  is 
erroneous  to  regard  all  epithelioma  as  cancerous,  some  of  the  cases 
being  only  evidence  of  disordered  epidermic  and  epithelial  cell  ac- 
tion, and  capable  of  perfect  cure. 

"  The  opinions  of  pathologists,  on  the  identity  of  epithelioma  and 
cancer,  are,  however,  yet  much  divided,  Paget,  Yelpeau,  and  Schuh 
regarding  it  as  cancer,  and  calling  it  epithelial  cancer,  while  Lebert, 
Hannover,  Bennett,  and  Lawrence  deny  its  cancerous  nature.* 
Lawrence  thus  arranges  the  arguments : 

*  Lawrence  on  Cancer,  1858. 
26 


402  ORAL  DISEASES  AND  SURGERY. 

I. For  Epithelioma  being  Cancer. 

"  1.  Its  infiltrating  character. 

"  2.  Its  tendency  to  infect  the  lymphatic  glands. 

"  3.  Its  tendency  to  recur  after  removal. 

"  4.  Its  fatality. 

II. — Epithdioma  is  not  Cancer. 

"  1.  From  the  excessively  rare  occurrence  of  consecutive  deposits. 

"  2.  Its  anatomical  structure. 

"  3.  The  absence  of  primary  cachexia. 

"  4.  Its  frequently  local  origin. 

"  A  careful  study  of  the  question,  seconded  by  some  experience, 
induces  me  to  regard  the  question  as  thus  correctly  stated : 

"  1st.  Epithelioma  exists  as  a  distinct  growth,  characterized  by 
epithelial  cells,  as  in  corns,  thickened  skin,  horns,  warts,  etc. 

"  2d.  These  may  become  the  seat  of  cancerous  action,  and  run  the 
course  of  cancer  to  degeneration,  though  in  the  least  marked  form, 
being  then  well  designated  as  '  cancroid.' 

"  3d.  There  is  a  cancer  of  the  skin  and  mucous  membranes,  origin- 
ating in  the  follicles,  that  presents  the  usual  elements  of  cancerous 
action  elsewhere,  which  yet  presents  epithelial  cells,  and  the  other 
normal  elements  of  the  tissue  invaded. 

"  4th.  Simple  epithelioma  is  to  be  regarded  as  really  a  hyper- 
trophy which,  when  inflamed  or  irritated,  ulcerates  and  undergoes 
the  usual  changes  of  healthy  inflammation. 

"  When,  as  is  sometimes  seen,  a  sebaceous  follicle  participates  in 
the  increased  epidermic  cell  action  of  epithelioma,  it  results  in  a 
thickened  growth  that  is  so  indurated  as  to  be  called  a  Horn.  Some 
of  the  instances  of  this  development,  and  especially  one  well  known 
to  visitors  in  Paris,  on  the  forehead  of  a  woman,  have  attained 
several  inches  in  length. 

"Anatomy  of  Epithelioma. — The  cut  surface  of  an  epithelioma 
is  generally  grayish  white  in  color,  and  the  texture  is  solid  or  semi- 
solid, quite  friable,  and  does  not  generally  yield  anything  resembling 
the  '  cancer  juice.'  Microscopic  examination  shows  infiltrated  among 
the  textures  of  the  part  affected,  great  numbers  of  cells  of  irregular 
shape,  ^-^g  to  -j-^^-^  of  an  inch  in  their  long  diameter,  which  more  or 
less  closely  resemble  normal  epithelial  scales ;  whence  the  name  of 
the  disease.     Besides  these  free  nuclei,  the   peculiar  bodies,  the 


EPITHELIOMA. 


403 


'globes  epidermiques '  of  Lebert,  and  the  'laminated  capsules'  of 
Paget,  can  be  observed,  as  well  as  spindle-shaped  cells,  which  are 
often  found  in  considerable  number,  according  to  Wedl,  who  asserts 
that  the  idea  that  epithelioma  exhibits  no  forms  which  cannot  be  re- 
ferred to  the  epithelial  type,  is  based  on  the  most  imperfect  research. 

"  Diagnosis. — A  clinical  diagnosis  can  generally  be  made  before 
the  removal  of  the  tumor,  if  the  age  of  the  patient  and  the  papillary 
character  of  the  growth,  as  well  as  its  locality,  be  regarded.  Occa- 
sionally ulcerated  scirrhus  of  the  skin  and  mucous  membranes,  and 
perhaps  lupus,  may  be  confounded  with  epithelioma.  Both  these 
errors  will,  however,  at  once  be  rectified  after  the  removal  of  the 
growth  and  a  study  of  its  minute  anatomy,  with  the  assistance  of 
the  microscope. 

"  Treatment. — Epithelioma  demands  varied  plans  of  treatment, 
in  accordance  with  the  nature  and  locality  of  the  growth.  Hard 
corns  and  the  scaly  varieties  are  often  cured  readily  by  protecting 
the  part  from  pressure,  or  by  softening  ointments  and  plasters. 
Condylomata  and  venereal  warts  may  be  destroyed  by  chromic  or 
nitric  acid  or  powerful  astringents.  The  same  treatment  is  applicable 
to  warts  on  the  hands  or  generative  organs,  not  the  result  of  syphilis, 
being  in  the  latter  case  consequent  on  inattention  to  cleanliness  or 
the  presence  of  acrid  discharges.  The  ulcerated  variety  will  gen- 
erally require  such  treatment  as  is  applicable  to  cancer  of  the  skin, 
under  which  head  it  will  be  stated.  Epithelioma  of  the  canthus  of 
the  eye,  alse  of  nose,  and  the  superficial  variety  seen  on  the  lip,  os 
uteri,  etc.,  is  best  treated  by  the  repeated  application  of  the  dry, 
powdered  sulphate  of  zinc,  as  proposed  by  Simpson,  of  Edinburgh, 
the  application  being  repeated  until  a  healthy  surface  is  produced, 
and  then  dressed  as  a  healthy  ulcer.  In  the  simpler  forms  seen  in 
the  OS  uteri  I  have  obtained  much  success  from  this  treatment.  The 
addition  of  powdered  gum  arable  will  dilute  the  application  when 
desired,  and  also  favor  its  adhesion  to  the  surface." 


PLATE    VIII. 

APPEARANCE   AND    POSITION   OP   SOME   OF   THE    TUMORS   SEEN   ABOUT 

THE    NECK. 

Fig.  1. — A  large  Cystoma  of  the  right  parotid  region,  caused  hy  the  devel- 
opment of  a  sebaceous  follicle  in  consequence  of  a  blow  upon  the 
part.  Commencing  as  a  lump  the  size  of  a  nut,  this  tumor  gradu- 
ally increased  to  nearly  the  size  of  the  head;  gave  exit  at  one 
time  to  sebaceous  matter  ;  had  a  broad  base  ;  was  nearly  immov- 
able ;  had  the  veins  enlarged  upon  its  surface,  and  showed  a  small 
ulceration  in  front,  from  which  fetid,  acrid,  and  bloody  sanies  had 
escaped.  As  the  tumor  enlarged  the  jaw  became  closed  ;  sensation 
of  the  face  diminished,  and  there  were  all  the  other  symptoms  due 
to  pressure  on  the  vessels  and  nerves  of  the  part.  The  tumor  dif- 
fers in  appearance  from  scirrhus  of  the  parotid  gland  in  its  size 
and  period  of  development.  It  was  readily  removed,  and  is  rep- 
resented as  an  example  of  one  of  the  class  of  tumors  of  the  parotid 
region  not  involving  the  parotid  gland. — After  Auvert. 

FiQ.  2. — Large  Adenoid  Tumor  of  the  Neck  dependent  on  degeneration  of 
the  lymphatic  glands  of  the  neck.  Arising  as  a  small  swelling 
caused  by  an  enlarged  gland  below  the  angle  of  the  jaw,  it  gradu- 
ally increased  until  it  occupied  the  entire  side  of  the  neck,  involv- 
ing many  glands,  and  reaching  from  above  and  behind  the  ear  to 
below  the  clavicle,  so  as  to  turn  the  head  to  the  opposite  side.  Its 
appearance  was  that  of  an  irregularly  lobulated  mass :  it  was  un- 
accompanied by  pain,  was  perfectly  firm  and  hard,  and  gave  no 
sense  of  fluctuation  at  any  point.  Under  the  use  of  chloroform  it 
was  successfully  removed  by  Mott. — After  Mott. 

FiQ.  3. — Appearance  of  an  immense  Adipose  or  Lipomatous  Tumor  of  the 
Neck.  This  tumor  was  not  painful ;  had  no  pulsation  ;  was  formed 
of  numerous  large  lobes,  with  the  superficial  veins  distended  over 
them,  and  was  attached  to  the  neck  by  a  large  pedicle  which  ex- 
tended from  the  angle  of  the  lower  jaw  on  the  right  side  down  to 
the  sterno-clavicular  articulation,  its  weight  being  so  great  that 
the  patient  could  hardly  retain  the  erect  position.  The  tumor  was 
found  to  be  covered  by  a  strong  capsule  formed  of  the  surrounding 
cellular  tissue',  and  to  have  originated  in  a  hypertrophy  of  the  sur- 
rounding adipose  tissue. — After  Auvert. 

Pig.  4. — A  large  Cystoma  of  the  left  Parotid  and  Submaxillary  Kegions, 
which  was  to  the  touch  semi-elastic,  unequally  lobulated,  and  due 
to  a  chronic  irritation  of  one  of  the  sebaceous  follicles,  the  duct 
of  which  had  become  closed,  and  thus  caused  a  retention  and  de- 
generation of  its  secretion. — After  Auvert. 

(404) 


CHAPTER    XXYIII. 

TUMORS   OF   PARTS   ASSOCIATED   WITH   THE    MOUTH. 

The  sebaceous,  the  cystic,  the  fatty,  and  the  glandular  tumors  are 
those  most  frequently  found  in  association  with  the  integuments. 

The  first,  the  sebaceous,  are  perhaps  the  most  common,  and  are 
as  simple  in  nature  as  they  are  easy  of  cure.  As  the  result  of  a 
blow  or  other  cause,  the  orifice  of  one  or  more  of  the  duets  of  the 
sebaceous  glands  becomes  obstructed ;  the  secretion  continuing  and 
having  no  outlet  becomes  necessarily  accumulated;  hence  the 
gradual  expansion  of  the  duct  and  formation  of  a  tumor.  As  this 
tumor  continues  to  enlarge  it  becomes  more  and  more  solid,  the 
result  of  the  absorption,  or,  if  not  this,  at  any  rate  the  disappear- 
ance of  its  more  liquid  contents,  until  finally,  to  the  touch,  it  be- 
comes springy  and  elastic.  A  section  of  such  a  tumor  exhibits  a 
delicate  cyst  wall  or  envelope,  and  cheesy  or  semi-fatty  contents ;  it 
is  seen  to  lie  in  the  integument  as  distinctly  as  a  walnut  lies  within 
its  hull. 

Sebaceous  tumors  are  found  of  every  size,  varying,  indeed,  from 
a  hazel-nut  to  a  foetal  head ;  they  are  generally  spheroidal  in  shape, 
but  frequently,  because  of  influences  exerted  by  neighboring  parts, 
become  changed,  even  to  a  lobulated  character. 

The  diagnosis  of  a  sebaceous  tumor  is  generally  not  at  all  difficult 
— it  rolls  under  the  touch,  can  be  circumscribed  by  the  grasp,  has  a 
detached  feel,  as  if  confined  to  its  place  alone  by  the  skin;  the  tis- 
sues enveloping  it  are  perfectly  healthy,  while,  however  large  it  may 
be,  no  evidences  are  given  of  constitutional  association.  Exceptions, 
however,  exist  to  this  simplicity  in  some  special  cases,  as,  for  ex- 
ample, where  the  presence  of  the  tumor  has  excited  inflammation  in 
the  surrounding  parts,  thickening  the  cyst  and  forming  attachments, 
or  where  the  attenuated  skin  has  ulcerated,  or  where  the  contents  of 
the  cyst  has  degenerated. 

Sebaceous  growths  are  only  to  be  gotten  clear  of  by  operation.  In 
many  cases  it  is  only  necessary  to  make  a  sufficient  incision  in  the 
skin,  and  the  tumor  can  be  enucleated,  just  as  the  crystalline  lens  is 

(405) 


406 


ORAL  DISEASES  AND  SURGERY 


removed  in  the  operation  for  hard  cataract.  In  other  cases  it  is 
necessary  to  incise  the  tumor  through  its  center  down  to  the  base ; 
this  exposes  the  cyst  or  sac,  which  is  to  be  dissected  away.  In  in- 
stances of  moderate  or  large  growths  it  is  the  practice  to  commence 
with  an  elliptical  incision,  making  the  skin  removed  correspond 
with  the  requirements  of  the  parts  after  the  tumor  shall  have  been 
taken  away.  In  doing  this  it  will  be  found  much  better  to  have  too 
much  than  too  little  integument — even  very  large  flaps  will  be  found 
soon  to  accommodate  themselves  to  the  parts  beneath. 

Fio.  86. — Small  Sebaceous  Tumor,  showing  its  sacculated  condition. 


The  contents  of  sebaceous  tumors,  while  really  of  a  common 
character,  yet  vary  very  much  not  only  in  appearance,  but  in  con- 
sistence. Yet,  whatever  this  consistence,  the  springy,  elastic  char- 
acter, as  the  touch  is  concerned,  is  preserved.  Prof.  Gross,  in  his 
"  System  of  Surgery,"  describes  such  tumors  as  of  soft  and  doughy 
consistence,  giving  this  as  one  of  the  diagnostic  features.  The  ob- 
servation certainly  differs  from  my  own,  and  I  am  at  a  loss  to  ex- 
plain such  difference.  These  tumors,  while  very  fi'equently  multi- 
form when  appearing  upon  the  scalp,  where  they  are  known  as  the 
common  wen,  yet  seldom  appear  but  as  single  upon  the  face. 

Sebaceous  tumors  have  little  vascularity,  the  supply  of  vessels 
being  confined  to  the  sac,  which,  as  will  be  inferred,  is  the  attenuated 
duct  and  glandular  substance  ;  hence  the  growth  is  of  very  slow 
character.  Little  or  no  pain  attends  the  development,  and  they  are 
entirely  devoid  of  danger,  as  any  tendency  to  malignant  degeneration 
is  concerned.  The  sac,  because  of  attachments  which  it  has  formed 
outside,  is  generally,  on  such  aspect,  rough  and  cellular-looking;  on 
the  inner  face,  on  the  contrary,  it  is  smooth  and  glistening. 


TUMORS   OF  PARTS  ASSOCIATED    WITH  MOUTH.     407 

Cystic  Tumors. — Cystic  tumors,  or,  more  justly  spcakiug,  cellu- 
lose tumors,  are  of  not  unfrequent  appearence  in  the  cheeks.  They 
might  be  described  as  an  hypertrophy  of  the  subcutaneous  cellular 
tissue,  and  would  be  very  well  represented  by  esteeming  them  as 
made  up  of  a  number  of  air  or  serum  injected  cells,  grouped  to- 
gether, and  limited  by  the  adjacent  fascias.  The  skin  above  such 
tumors  is  always  attenuated  and  generally  discolored,  even  to  an  ap- 
proach to  purple,  looking,  indeed,  as  if  just  ready  to  slough  awav, 
and  yet  being  tenacious  of  its  vitality  to  an  extent  quite  wonderful. 
Similar  tumors  are  occasionally  found  in  the  substance  of  the  lips, 
but  are  much  more  apt,  in  this  situation,  to  be  made  up  of  a  single 
cell  rather  than  many.  In  origin  they  may  be  said  to  be  idiopathic, 
coming,  as  it  were,  of  themselves,  and  occasionally  disappearing  as 
spontaneously,  having,  in  the  interim,  failed  to  respond  in  the 
slightest  degree  to  treatment. 

These  tumors,  unless  in  situations  which  permit  of  the  use  of 
the  knife,  which  is  their  effectual  cure,  are  found  very  difficult  to 
manage ;  the  only  thing  that  ever  seemed  to  me  of  the  slightest 
service  was  the  daily  smearing  of  the  surface  with  creasote  ointment, 
and  this  practice  will  be  found  unsatisfactory  enough.  In  their 
treatment  I  have  broken  up  the  cells,  have  laid  the  tumor  open  in 
bulk,  and  stuffed  the  cavity,  have  used  every  conceivable  kind  of  an 
injection,  and  then,  completely  discouraged  and  baffled,  have  left  the 
case  to  nature,  which,  after  six  months,  or  it  might  be  a  year  or 
more,  would  finally  effect  a  cure. 

The  most  common  seat  of  such  tumors  is  over  the  line  of  the 
Stenonian  duct ;  and,  if  I  had  not  succeeded  in  satisfying  myself 
thoroughly  to  the  contrary,  I  would  have  to  believe  that  some  con- 
nection existed.  Whether  cured  by  nature,  with  or  without  assist- 
ance, they  are  peculiarly  liable  to  recur.  I  have  known  them  appear 
and  disappear  as  many  as  half  a  dozen  times.  They  seldom  rise 
much  above  the  level  of  the  cheek,  are  oblong  in  shape,  and,  indeed, 
now  that  the  idea  just  strikes  me,  look  more  like  a  varicose  vein 
with  hypertrophied  valves  than  anything  else  to  which  perhaps  one 
might  compare  them. 

Another  kind  of  cystic  tumor,  appearing  in  the  integuments  of  the 
face,  occasionally  met  with,  may  be  compared  to  a  cyst  of  cartilage. 
Such  cysts  seem  to  prefer  as  a  locality  the  side  of  the  nose,  and  when 
in  this  situation  are  connected  with  the  lateral  cartilages.  If  opened 
from  beneath,  they  will  discharge,  on  compression,  a  puslike  fluid,  but, 
in  a  very  few  minutes  after  such  pressure  is  removed,  will  refill,  or 


408 


ORAL  DISEASES  AND  SURGERY. 


will,  at  least,  reassume  their  original  form,  recovering,  perhaps,  by 
the  elasticity  which  resides  in  them 

Another,  and  the  only  other  situation  in  which  I  have  met  with 
such  tumors,  is  in  the  substance  of  the  lip  ;  but  here  they  more  re- 
semble fibro-cartilago  than  when  upon  the  side  of  the  nose.  Extir- 
pation by  the  knife  is  the  proper  treatment,  although  it  not  unfre- 
quently  happens  that  a  cure  may  be  effected  by  cutting  into  the  cyst, 
scarifying  its  walls,  and  stuffing  with  medicated  lint;  the  tinct.  of 
iodine  being  used  first,  and  alum-water  and  capsicum  after. 

Fig.  87. — Cartilaginous  Cyst. 


Fatty  Tumors. — The  fatty  tumors  are  much  more  common  to 
the  posterior  and  lateral  aspect  of  the  neck  than  to  the  face.  Where- 
ever  appearing,  however,  they  are  recognized  by  their  extreme  slow- 
ness of  growth,  by  the  tissues  overlying  them  being  unaffected,  by 
the  absence  of  pain,  and  of  constitutional  association.    To  the  touch 


TUMORS  OF  PARTS  ASSOCIATED    WITH  MOUTH.     409 

they  are  not  so  diagnostic,  being  at  one  time  springy  and  elastic,  at 
another  dull  and  doughy.  Being  an  hypertrophy  of  the  common  fatty 
tissue,  they  are  not  distinct  and  circumscribed  as  the  sebaceous,  con- 
sequently are  of  broader  and  more  diifused  base  ;  such  tumors  may  or 
may  not  be  sacculated,  such  sacculation,  however,  referring  to  a  very 
imperfect  cyst  even  when  any  signs  of  one  may  be  present.  Fatty 
tumors  seldom  manifest  any  tendency  to  degeneration,  troubling 
more  from  a  constantly  increasing  bulk,  and  the  annoyance  of  their 
presence,  than  from  any  real  harm  inflicted.  Fig.  3  in  the  plate  rep- 
resents a  most  unusual  form  of  the  lipomatous  tumor,  a  case  such  as 
is  seldom  met  with.  In  this  instance  the  growth,  from  its  very 
weight,  has  become  pedunculated,  the  vascular  enlargement  being  a 
natural  and  simple  result  of  mechanical  interference  with  the  circu- 
lation. Fatty  tumors  are  only  to  be  treated  by  the  knife  ;  it  is  simply 
a  waste  of  time  to  try  other  means. 

Fig.  88. — Lobulated  Lipomatous  Tumor — after  Miller. 


Glandular  or  Adenoid  Tumors. — Glandular  tumors,  represented 
in  the  plate.  Fig.  2,  belong  markedly,  although  not  exclusively,  to 
the  scrofulous  condition,  being  found,  most  generally,  upon  persons 
so  affected.  These  tumors  are  generally  situated  upon  the  side  of 
the  neck,  involving  one  or  more  of  the  superficial  ganglionic  chain. 
In  undecided  cases  I  have  known  them  of  such  torpidity  that  two  or 
three  years  would  scarcely  suffice  to  develop  them  to  the  size  of  a 
walnut,  while,  in  other  cases,  the  enlargement  will  be  so  rapid  that 
a  very  few  months  may  be  sufficient  to  obtain  the  prominence  marked 
in  the  plate.  Unlike  the  previous  classes  of  growths,  the  adenoid 
are  very  susceptible  to  constitutional  and  local  treatment,  being,  in 


410 


ORAL  DISEASES  AND  SURGERY. 


such  manner,  quite  as  frequently  caused  to  disappear  as  by  the  use 
of  the  knife. 

Fig.  90. — Yiew    of    Fatty  Tumok 

PiQ,  89. Microscopic  Structure         removed  from  ukder  the  Tongue 

OF  AN  Adipose  Tumor  (Bennet).  (Liston). 


When  appearing  upon  the  face,  such  tumors  imply  the  enlarge- 
ment of  the  buccal  glands ;  in  these  instances  they  are  not  so  apt  to 
have  the  scrofulous  association  as  when  found  upon  the  neck.  In 
considering  such  growths,  we  are  primarily  to  investigate  the  cause 
or  causes  exciting  to  their  development.  Scrofula,  the  common 
cause,  has  been,  to  some  extent,  considered  in  another  part  of  this 
work ;  its  general  recognition  as  a  dyscrasiac  disease  suggests  the 
necessity  of  such  a  course  of  medication  as  shall  tend  to  restore  the 
lost  tone,  and  build  up  the  system  at  large  ;  hence  the  use  of  tonics 
so  freely  prescribed  in  such  connection.  Regarding  the  local  reme- 
dies to  be  employed,  a  common  preference  seems  to  be  given  to  the 
iodine  in  tincture.  Overstimulation,  however,  it  is  not  to  be  forgot- 
ten, is  quite  as  bad,  or  even  worse,  than  no  stimulation  at  all,  and, 
by  a  too  free  use  of  this  agent,  even  more  harm  than  good  can  be 
done.  Harmony  in  the  system  at  large  being  secured,  it  will  be 
found  to  need  very  little  local  stimulation  to  provoke  absorption 
in  the  tumor ;  hence  a  philosophical  treatment  of  such  cases  con- 
siders not  only  medicaments  proper,  but  the  bath,  dress,  food,  exer- 
cise, etc. 

A  local  treatment  to  be  used  in  very  indolent  growths,  consists  of 
equal  parts  of  the  belladonna  and  mercurial  ointments.  Such  an 
ointment,  in  my  experience,  causes  these  tumors  to  absorb  very 
rapidly,  or  otherwise  to  degenerate  into  pus.  I  have  used  this 
combination  in  many  cases  with  the  most  satisfactory  results. 

Another  mode  of  treatment  is  by  the  blister.  For  this  purpose 
the  cantharidal  collodion  will  be  found  admirably  adapted.    Blisters 


TUMORS   OF  PARTS  ASSOCIATED    WITH  MOUTH.     411 

should  be  in  proportion  to  the  size  of  the  tumor,  never  covering 
more  than  an  eighth  or  quarter  of  its  free  surface. 

In  cases  where  it  may  be  thought  preferable  to  use  the  knife, 
should  the  tumor  be  upon  the  face,  the  incisions  are  to  be  made  in 
the  line  of  the  underlying  muscles,  thus  insuring  as  little  deformity 
as  possible  from  the  scar. 

Adenitis  from  a  syphilitic  association  may  yield  tumors  of  the 
cervical  and  buccal  glands.  A  diagnosis  in  these  cases  is  secured 
from  the  history  of  the  case,  or,  if  this  is  not  to  be  procured,  an  en- 
largement will  always  be  found  to  be  associated  in  the  posterior 
cervical  chain.  This  is  a  most  diagnostic  sign,  and  will  seldom 
mislead. 

ACCIDENTAL  TUMORS. 

Tumors  of  the  parts  we  are  considering,  which  might  be  termed 
accidental,  are  the  erectile,  the  lepidoid,  the  verrucous,  the  keloid, 
and  the  horny. 

Angionoma,  Yascular,  or  Erectile  Tumors. — Under  this  desig- 
nation are  included  naevi  materni,  or  mother  marks,  and  the  venous, 
arterial,  and  capillary  growths. 

Naevi,  as  suggested  by  Professor  Smith,  cannot  always  come 
justly  under  the  designation  of  tumors,  from  the  fact  that  they  fre- 
quently exist  without  apparent  elevation ;  situated  in  the  skin,  yet 
producing  no  visible  thickening  of  it.  These  marks  are  of  very 
various  size,  form,  and  color,  being  sometimes  found  several  inches 
in  length,  and  again  as  mere  spots.  In  form  they  may  represent 
certain  familiar  objects,  as  fruits,  animals,  etc.  The  color  of  them, 
generally,  some  shade  of  red,  varies  from  the  arterial  scarlet  to  the 
dull  purple  of  a  venous  congestion.  Nsevi,  even  although  to  the  eye 
they  may  not  in  many  instances  appear  vascular,  yet  certainly  differ 
only  in  degree  from  the  telangiectasis,  being  commonly  capillary 
hypertrophies,  as  is  sufficiently  witnessed  when  wounds  occur  in 
them.  That  such  vascularity  does  not,  however,  shade  off  into  the 
adjoining  tissue  is  sufficiently  well  recognized ;  indeed,  just  the  con- 
trary, the  connection  being  indeed  very  limited.  Such  tumors  are 
supplied  by  two  or  three  large  vessels,  the  hypertrophy  of  whose 
radicles  may,  for  practical  purposes,  be  esteemed  as  constituting  the 
tumor;  hence,  in  operating  on  such  growths,  if  the  incisions  are 
made  wide  of  the  tumor,  there  is  found  no  more  perhaps  than  ordi- 
nary hemorrhage — one  or  two  vessels  alone  demanding  the  ligature. 

Arterial  Tumor. — This  is  a  form  of  the  erectile  growths  which 


412  ORAL  DISEASES  AND   SURGERY. 

has  an  individuality,  inasmuch  as  it  consists  fairly  of  a  congeries  of 
vascular  twigs,  held  together  by  the  more  or  less  imperfect  remains 
of  the  associated  skin  and  cellular  tissue.  It  is  not,  as  has  been  sug- 
gested, an  aneurism,  but  is  rather  a  simple  enlargement  of  terminal 
vessels,  proven  from  the  fact  that  such  enlargement  accompanies  the 
vessels  of  supply  for  a  greater  or  lesser  distance ;  that  it  differs, 
however,  from  the  naevi,  just  described,  few  are  prepared  to  admit. 
It  is,  perhaps,  a  formidable  nsevus,  but  nothing  more,  both  being,  in 
varying  degrees,  erectile  tumors. 

The  origin  of  these  growths,  while  in  many  instances  referable 
to  local  injuries,  yet  in  most  cases  are  fairly  to  be  presumed  of  con- 
genital character.  It  is  very  true  that  they  may  appear  even  later 
in  life,  yet  the  impress  existed,  although  it  might  have  been  but  a 
little  red  spot  not  larger  than  the  head  of  a  pin,  and  may  have  en- 
tirely escaped  attention. 

The  growth  of  such  tumors  is  markedly  variable.  I  have  met 
with  them  where  twenty  years  seemed  scarcely  to  have  changed 
their  character,  while  in  other  instances  a  single  week  has  exhibited 
alarming  progress.  In  some  cases  the  attenuation  of  the  coats  of 
the  vessels  is  so  great  that  one  might  well  imagine  he  can  see  the 
flow  of  the  blood,  while  in  other  instances,  a  hypertrophy  of  the 
associate  tissues  is  so  marked  as  to  comparatively  solidify  the  part. 
In  color  the  arterial  tumor  will  also  be  found  to  vary,  the  shading 
being  influenced  by  the  conducting  facility  of  the  veins  which  are 
to  pass  off  the  circulation.  Pulsation  exists  in  many  of  the  cases, 
and  is  synchronous  with  the  ventricular  systole.  To  the  touch,  the 
tumors  are  soft  and  doughy,  being  made  to  almost  disappear  under 
pressure,  yet  filling  up  the  moment  such  pressure  is  removed;  they 
have  no  definite  form,  the  outline  being  modified  by  circumstances, 
of  which  we  know  nothing.  One  marked  diagnostic  sign  of  such 
tumors  is  the  effect  produced  on  the  size  by  the  condition  of  the 
circulation;  verat.  viride,  or  digitalis,  by  lowering  the  action  of 
the  heart,  will  almost  cause  those  of  moderate  size  to  disappear. 
Even  the  quietude  of  sleep  and  recumbency  markedly  affect  them. 
Passion,  on  the  other  hand,  excitement,  or  any  mental  emotion  dis- 
turbing the  pulse,  will  cause  them  to  enlarge,  even  in  some  instances 
to  bursting,  such  enlargement  being  most  marked  in  cases  where  a 
state  of  atrophy  characterizes  the  connective  tissue.  The  common 
danger  from  these  tumors  is  ulceration,  which,  in  many  instances, 
resulting  in  severe  hemorrhage,  has  gradually,  if  not  suddenly, 
exhausted  the  patient. 


TUMORS   OF  PARTS  ASSOCIATED    WITH  MOUTH.     413 

The  Venous  Tumor. — This  is  still  another  form  of  the  erectile 
growths,  differing,  however,  from  the  one  just  described,  in  the  fact 
that  the  venous,  rather  than  the  arterial,  twigs,  are  in  a  state  of  en- 
largement. A  description  of  the  one  is  a  description  of  the  other, 
saving  in  the  matters  of  color  and  pulsation,  the  latter  being  gen- 
erally dark,  almost  to  a  dull  purple  or  grayish-black,  and  of  course 
deficient  in  pulsation.  Like  the  arterial,  the  venous  tumors  are 
sometimes  slow  of  growth,  at  other  times  rapid;  they  appear  without 
assignable  cause,  other  than  the  congenital  impress. 

Fig.  91. — Venous  Tumor. 


Treatvient. — Nsevi  are  treated  on  a  common  principle  ;  by  ampu- 
tation with  the  knife,  by  strangulation,  by  compression,  by  injection, 
and  by  the  application  of  caustic  remedies. 

Excision  is  chiefly  confined  to  small  tumors,  before,  as  remarked 
by  Prof  Gross,  they  have  acquired  much  functional  activity,  or 
given  rise  to  any  marked  enlargement  of  the  neighboring  arteries. 
In  these  cases  excision  is  the  easiest  and  most  rapid  way  of  getting 
clear  of  them.  The  general  experience  to  cut  as  wide  of  the  growth 
as  convenient  is  the  principal  rule  ;  as  the  vessels  of  supply  are  cut, 
an  assistant  compresses  them  with  thumb  or  finger  ;  and  while  such 
vessels  are  frequently  very  formidable  looking,  yet  it  may  happen 
that  when  the  tumor  is  entirely  away,  not  a  single  ligature  shall  be 
required.  Should  the  hemorrhage  not,  however,  cease,  it  will  be 
found  the  easiest  matter  to  catch  them  with  the  forceps  or  tenaculum, 
and  throw  a  ligature  around  them. 

A  removal  effected,  and  the  bleeding  controlled,  nothing  remains 
but  to  close  the  wound  with  a  few  stitches  of  the  interrupted  suture, 
and  to  support  it  with  adhesive  strips. 


414  ORAL  DISEASES  AND   SURGERY. 

Strangulation,  the  most  common  mode  of  operation,  is  effected  by 
transfixing  the  tumor  with  one  or  more  ligatures,  and  thus  sloughing 
it  away.  As  a  general  rule,  it  will  be  found  necessary  to  transfix 
skin  as  well  as  tumor  ;  but  should  cases  present  where  the  overlying 
parts  arc  healthy,  then  a  crucial  incision  may  be  made,  and  the  flaps 
laid  off  before  such  transfixion ;  the  tumor  removed,  the  flaps  are 
laid  back  in  place,  and  dressed  secundum  artem. 

Compression  applies  to  pressure  however  made.  Take  a  piece  of 
ivory,  metal,  or  other  convenient  material,  adapt  it  to  the  part,  and 
confine  by  means  of  bandage  or  adhesive  strips.  This  mode  of  cure 
is  rarely  applicable,  being  used  only  over  bony  surfaces,  and  where 
the  tumor  is  quite  small.  A  practice,  which  in  one  instance,  where" 
the  tumor  was  situated  upon  the  finger,  answered  a  satisfactory  pur- 
pose, consisted  in  the  daily  application  of  tinct.  iodine  four  times  the 
officinal  strength,  together  with  the  use  of  an  india-rubber  ring. 
Collodion,  daily  applied,  has  been  recommended 

Injections  have  many  advocates  :  of  agents  thus  used,  the  princi- 
pal are  iodine,  Monsel's  solution,  nitric  acid,  and  creasote.  Such 
mode  of  treatment  is  always,  however,  more  or  less  risky,  and  is  not 
to  be  commended.  The  practitioner  disposed  to  try  it  has  only  to 
use  the  ordinary  subcutaneous  syringe,  break  up,  with  its  point,  the 
structure  of  the  tumor,  or  some  portion  of  it,  and  follow  with  the  in- 
jection.    Several  cases  of  death  are  on  record  from  such  injections. 

Caustic  remedies,  used  to  destroy  such  tumors,  are  of  various 
kinds, — the  Vienna  paste  being  mostly  preferred  ;  this  is  the  potassa 
cum  calce  of  the  pharmacopoeia:  it  is  used  by  making  an  applica- 
tion of  from  ten  to  twenty  minutes,  succeeding  it  with  an  emollient 
poultice. 

Another  method  is  to  paint  the  part  with  the  blistering  collodion, 
and,  after  the  cuticle  is  raised,  apply  crystals  of  the  chloride  of  zinc. 

Landolfi's  caustic  is  thus  composed : 

B. — Bromin.  chlorid.  3  parts; 
Zinci,  2  parts  ; 
Antimon.  1  part ; 
Pulv.  rad.  glycyrrh.  1  part.  M. 

Still  another  is  called  Fell's.     It  is  composed  as  follows : 

R. — Pulv.  rad.  sanguinar.  Canaden.  ^i ; 
Zinci  chl.  Jij ; 
Aqua,  f5ij. 
This  is  paixed,  forming  a  thick  paste. 


TUMORS   OF  PARTS  ASSOCIATED    WITH  MOUTH.     415 

The  application  of  Dr.  Mackey,  of  Edinburgh,  is  as  follows : 

R. — Hydrarg.  bichlor.  4  parts  ; 
Collodion,  30  parts.  M. 

Paint  the  part  thoroughly ;  four  hours  afterward  apply  a  warm- 
water  dressing  ;  the  eschar  will  slough  out  in  from  three  to  six 
days. 

In  the  application  of  any  caustic,  trouble,  more  or  less  severe, 
from  a  resulting  inflammation,  is  always  to  be  anticipated  ;  this 
every  patient,  or  the  friends,  should  understand,  as  it  is  impossible 
to  know  just  how  a  case  shall  come  out.  After  the  use  of  a  caustic, 
and  the  slough  of  the  part,  the  resulting  wound  is  to  be  esteemed 
and  treated  as  a  simple  ulcer. 

Starvation  is  still  another  method  of  treating  the  erectile  growths. 
This  consists  simply  in  finding  the  vessel  or  vessels  of  supply,  and 
cutting  off  the  circulation  by  ligation ;  this  mode  has  many  advo- 
cates, and  is  certainly  well  where  the  vessels  are  in  a  position  to  be 
conveniently  operated  on. 

The  seton  is  still  another  mode.  This  is  introduced  by  threading 
the  needle  with  tape  or  other  material,  and  passing  it  beneath  the 
growth.  The  seton,  whatever  the  material,  should  be  as  large,  if 
not  larger,  than  the  needle  which  carries  it ;  thus,  by  the  pressure 
secured,  guarding  against  hemorrhage. 

In  considering  the  treatment  of  nsevi,  it  is  not  to  be  forgotten  that 
there  are  cases  which,  if  left  to  themselves  long  enough,  might 
effect  self-cure.  Young  children,  afflicted  with  nsevus,  are  hurried 
to  the  surgeon,  under  the  impression  that  it  must  necessarily  spread, 
and  that  therefore  the  sooner  the  disease  is  removed  the  better. 
Such  haste  will  not  always  be  found  necessary,  or  even  prudent. 
For  a  short  time  after  birth  a  nsevus  may  continue  to  grow — for 
several  weeks,  perhaps,  then  it  may  cease  to  enlarge.  If  it  is  of  a 
simple  cutaneous  variety,  it  may  become  the  seat  of  ulceration; 
this  may  spread,  but  it  will  destroy  the  naevus.  In  other  instances, 
a  naevus,  after  growing  to  a  considerable  size,  will  become  the  seat 
of  atrophy,  will  dwindle,  shrink,  and  degenerate,  until  little  or 
nothing  of  it  is  left. 

Lepidoid  Growths. — The  lepidoid  growths  are  generally  mul- 
tiple, inferred,  primarily  at  least,  to  be  strictly  epithelial  in  char- 
acter, and  exhibit  themselves  as  elevated  patches  of  varying  size, 
scattered  irregularly  over  the  parts  affected,  the  common  localities 
being  the  cheeks,  nose,  and  forehead. 


416  ORAL  DISEASES  AND  SURGERY. 

The  orio"in  of  the  term,  from  Aejrt?,  a  scale,  and  devdpov,  a  tree, 
affords  the  idea  of  the  condition  the  part  presents,  simply  a  number 
of  scattered  barklikc  scales  separated  by  healthy  skin.  The  dis- 
ease without  any  doubt,  is  most  common  to  persons  of  sandy  and 
florid  complexion,  having  light  or  reddish  hair,  with  marked  cuta- 
neous circulation. 

Appearing  first  as  scales  not  larger  than  a  pin's  head,  the  disease 
may  year  by  year  progress,  until  finally  the  scales  which,  like  all 
epithelial  tissues,  have  been  falling  off  and  renewing  themselves, 
cease  to  develop,  leaving  ulcers.  The  dermis  beneath  exhibits  a 
granular,  glossy  surface,  looking  like  limited  fungi  glazed  with 
lymph;  the  intermediate  skin  soon  becomes  dense  and  fibro-cartila- 
ginous,  and  if  not  cured,  cancerous  degeneration  succeeds. 

In  the  treatment  of  this  condition,  the  paint,  composed  of  tinct. 
of  iron  and  quiuia,  will  be  found  most  reliable.  If,  however,  it 
should  not  effect  an  immediate  good,  it  is  better  to  at  once  dispense 
with  its  use,  and  depend  strictly  upon  constitutional  influences.  As 
a  common  wash  or  simple  source  of  protection,  bran-water  will  be 
found  very  soothing.  A  local  application  as  follows  has  also  been 
highly  recommended : 

B. — Hydrarg.  bichl.  gr.  i ; 
Glycerin, 
Eau  de  Cologn.  aa  ^ss.     M. 

Verrttcous  Growths — Warts. — Warts  upon  the  alse  of  the  nose 
are  familiar  objects  to  every  one.  They  consist  of  an  hypertrophy 
of  the  papillary  structure,  and  are  frequently  covered  with  a  sort  of 
secondary  growth,  as  in  what  are  known  as  the  seed-warts;  the 
structure  is  essentially  cellulo-fibrous. 

Warts  are  not  only  objectionable  from  the  stand-point  of  a  de- 
formity they  produce,  but  when  situated  upon  the  face  seem  pecu- 
liarly inclined  to  degenerate,  assuming  a  vascularity  which  always 
impresses  as  threatening.  In  treating  a  wart,  the  practitioner  may, 
if  he  choose,  first  apply  dilute  chromic  acid ;  this,  in  many  instances, 
will  blacken  and  kill  the  growth,  the  tumor  sloughing  away  in  the 
course  of  five  or  six  days,  leaving  the  resulting  ulcer  a  perfectly 
simple  one.  But  chromic  acid  is  not  to  be  applied  to  the  vascular 
wart;  on  the  contrary,  if  irritable,  as  generally  first  seen  by  the 
practitioner,  they  are  to  be  soothed  by  the  most  gentle  of  applica- 
tions, after  which  they  are  be  thoroughly  removed  with  the  knife — 
a  rule  always  good  in  this  direction  is  "Do  not  irritate."     I  have 


TUMORS   OF  PARTS  ASSOCIATED    WITH  MOUTH.     417 

seen  many  a  vascular  wart  provoked  into  the  most  alarming  of  as- 
pects. A  wart,  situated  upon  the  face,  unless  like  the  simple,  hard, 
insensible  excrescence  as  met  with  upon  the  hands,  cannot  be  too 
carefully  or  judiciously  treated. 

Keloid  Tumors. — Keloide,  the  French  term,  signifying  a  disease 
resembling  scirrhus,  is  the  name  given  to  one  of  the  most  peculiar 
and  inexplainable  of  the  skin  affections.  This  condition,  first  de- 
scribed by  Alibert,  is  characterized  by  nodules,  or  more  generally 
wheals,  scattered  irregularly  about  the  body — most  commonly,  how- 
ever, confined  to  the  breast,  arms,  neck,  and  face.  It  occurs  in  both 
sexes,  may  appear  at  any  time  of  life,  and  is  thought  to  be  more 
common  to  the  black  than  to  the  white 

Keloid  is  a  disease  of  the  skin  and  subcutaneous  cellular  tissue. 
That  it  is  an  atonic  condition  is  inferred  in  my  own  mind  from  the 
fact  that  in  every  individual  case  in  which  I  have  seen  it  there 
seemed  to  be  a  scrofulous  association.  This,  however,  may  have 
been  accidental,  as  I  do  not  find  it  referred  to  by  others. 

Of  the  exciting  causes  of  keloid,  dermatologists  express  no  opinion : 
it  is  traumatic,  and  it  is  idiopathic;  it  appears  upon  a  skin  which 
before  has  seemed  entirely  healthy,  and  it  springs  up  in  the  cicatricial 
tissue  of  a  wound.  The  cicatrices  of  bad  burns  from  dry  heat  very 
frequently  so  represent  this  disease  that  one  might  be  readily  mis- 
taken for  the  other.  Keloid  certainly  constitutes  a  diathesis ;  I 
have  seen  it  develop  after  a  simple  puncture  which  opened  a  boil, 
while  the  observations  of  others  have  remarked  it  appearing  in  the 
cicatrices  of  smallpox,  after  scarification  in  cupping,  after  vaccina- 
tion, blistering,  etc.  Processes  or  roots  pass  into  neighboring 
parts,  thus  extending  the  disease;  the  excrescences,  to  the  touch 
are  hard,  semi-elastic,  and  rough;  the  color  differs  from  the  sur- 
rounding parts — varying  as  do  the  cicatrices  of  burns.  According 
to  the  observations  of  Professor  Gross  the  parts  itch  and  are  more 
or  less  uncomfortable.  Any  peculiar  sensation  I  have  myself, 
however,  never  heard  complained  of,  except,  indeed,  as  the  loca- 
tion of  some  wheal  would  interfere  by  its  stiffness  with  free  motion 
in  a  part. 

A  keloid  tumor  seems  to  be  an  imperfect  fibrous  development,  a 
species  of  sarcoma — although  it  certainly  differs  from  the  latter  con- 
dition in  never,  as  far  as  I  know,  tending  to  degenerate. 

Treatment. — This  has,  in  every  instance,  proved  so  unsatisfac- 
tory, that  surgeons  are  agreed  in  the  practice  of  letting  them  alone ; 

27 


418  ORAL  DISEASES  AND  SURGERY. 

even  the  knife  is  useless,  or  worse  than  useless ;  if  a  nodule  or 
wheal  be  removed,  one  or  perhaps  half  a  dozen  will  certainly  spring 
up  in  its  place.  Where  the  tumors  interfere  much  with  motion,  they 
may  be  lubricated  with  glycerin  or  oil,  but  otherwise  nothing  can 
be  effected  by  treatment — the  only  satisfaction  to  be  derived  by  the 
patient  resides  in  the  consciousness  that  keloid  never  degenerates 
into  cancer. 


CHAPTER    XXIX. 

THE   ANTRUM    OP   HIGHMORE,  AND   ITS   DISEASES. 

Eighteen  years  spent  in  a  direction  of  practice  which  should 
have  afforded  every  opportunity  for  observation,  and  as  well  a 
scope  of  view,  which  necessarily  offers  to  one  who  is  not  an  un- 
frequent  visitor  at  hospitals  and  clinics — combine  to  impress  me 
with  the  truthfulness  and  propriety  of  the  conclusion,  that  the  dis- 
eases of  the  antrum,  outside  of  such  tumors  as  have  been  described,  are, 
for  the  most  part,  simple  in  character,  easy  of  diagnosis,  and  not,  as 
a  rule,  at  all  difficult  of  treatment.  Indeed,  I  have  not  unfrequently 
thought  that,  for  the  purpose  of  general  study,  one  would  not  be 
entirely  without  justification  in  asserting  that  there  were  but  two 
sources  of  trouble  to  be  found  in  this  cavity ;  the  first,  and  prom- 
inent, being  lesions  secondary  to  the  diseases  of  the  teeth.  The 
second,  the  troubles  common  to  mucous  membranes,  wherever 
situated. 

Certain  I  am,  at  any  rate,  that,  without  fear  of  successful  contra- 
diction, I  may  assert  that  the  great  majority  emanate  from  the  first 
of  these  directions ;  while  the  atonic  conditions,  represented  by  the 
dropsies,  the  puruloid  secretions,  the  mucous  engorgements,  and  the 
ulcerations,  are  nothing  different  from  the  ordinary  mucoid  affections, 
except  as  modifications  may  be  made  by  situation,  the  last  being  con- 
clusively proven,  I  think,  by  the  fact  that  what  is  the  cure  of  the 
one  is  the  cure  of  the  other. 

While  thus  asserting,  however,  that  in  these  two  directions  lie 
the  chief  sources  of  trouble,  I  would  not  by  any  means  be  understood 
as  implying  that  the  subject  is  unworthy  investigation  outside  of 
such  considerations ;  on  the  contrary,  I  am  bound  to  confess  that  I 
find  recorded  more  than  one  description  of  diseases  of  the  cavity, 
which  to  me,  at  least,  are  as  anomalous  on  principle  as  they  are  in 
description,  and  which  I  can  only  explain  on  the  ungenerous  sup- 
position that  the  authors  must  have  drawn  somewhat  on  their  de- 
scriptive powers,  or  otherwise  that  the  antrum  has  some  of  the 
strangest  anomalies. 

(419) 


420  ORAL  DISEASES  AND  SURGERY. 

Again,  as  a  class  coming  between  these  uncommon  and  the  common 
affections,  wo  have  it,  not  at  all  indirectly,  that  there  exists  sequela 
of  certain  of  the  exanthemata  which  have  a  special  and  peculiar 
affinity  for  this  cavity;  while,  in  sj-jihilis,  I  have  myself  seen  the 
very  first  event  in  the  secondary  train  exhibiting  itself  in  a  dis- 
turbance of  this  sinus.  That  this  latter,  however,  is  rare,  I  well 
know  from  observation  extending  over  thousands  of  cases  in  hos- 
pital ;  indeed,  syphilitic  troubles  of  the  antrum  are  so  infrequent 
even  in  the  tertiary  stage  of  that  affection,  that  my  observations 
would  lead  to  the  inference  that  the  cavity  never  takes  on  the  disease 
unless  when,  from  continuity  of  structure,  it  absolutely  has  forced 
upon  it,  as  it  were,  the  trouble,  either  from  its  relationship  with  the 
hard  palate  in  the  oral  direction,  or  with  the  turbinated  bones  in  the 
nasal ;  for,  while  the  practitioner  will  surely  hear  complaints,  yet,  if 
he  investigates  the  cause  of  trouble,  he  will  find,  as  I  so  often  have, 
that  mercurial  inflammation  of  periodontal  membranes  is  the  source 
of  offense,  rather  than  the  specific  condition.  Clumsily  performed 
surgical  operations  are  also  the  occasional  causes  of  morbid  conditions 
being  set  up  in  the  cavity,  and  which,  when  existing,  would  of  course 
be  so  evident  as  to  force  the  consideration  of  them  upon  the  atten- 
tion— the  most  common  of  these  being  the  breaking  of  the  fangs  of 
teeth  in  attempts  to  extract  these  organs. 

With  these  preliminary  remarks,  we  pass,  then,  at  once  to  a  con- 
sideration of  the  premised  principal  cause  of  antral  trouble — diseased 
teeth. 

In  the  chapter  treating  on  "Anomalies  of  Dentition,"  attention 
was  directed  to  the  close  relationship  of  the  fangs  of  several  of  the 
teeth  with  the  floor  of  the  antrum,  and  to  the  fact  that  it  was  not 
unfrequent  to  find  these  fangs  —  particularly  the  palatine  of  the 
second  molar — penetrating  the  sinus,  thus  associating  their  peri- 
osteums,  and  furnishing  a  continuity  of  structure. 

In  the  same  chapter  attention  was  also  called  to  such  diseases 
and  conditions  of  the  alveolar  border  as  were  apt  secondarily  to 
affect  the  antrum  ;  means  of  diagnosis  and  treatment  being  sug- 
gested. The  reader  who  may  feel  sufficient  interest  in  the  subject 
might  find  it  not  amiss  to  review  the  chapter  alluded  to,  before  pro- 
ceeding to  the  consideration  of  the  clinical  cases  presented,  and 
which,  I  think,  will  sufficiently  illustrate  this  department  of  diseases 
of  the  antrum. 

Case  I. — Indolent  Tumor  on  the  Right  Cheek. — A  woman  had 


ANTRUM   OF  HIGHMORE  AXD   ITS  DISEASES.    421 

an  indolent  tumor  on  the  right  cheek  about  the  size  of  a  pigeon's 
egg,  occasioning  much  disfigurement,  but  altering  the  color  of  the 
skin  very  slightly.  The  patient  had  often  suffered  violent  toothache 
on  this  side,  and,  though  young,  had  few  teeth  now  remaining,  and 
these  all  carious;  otherwise  she  was  in  very  good  health.  The 
tumor  was  prominent  toward  the  cheek,  palate,  and  nostril,  yielded 
on  pressure,  and  gave  a  slight  noise  as  it  returned  to  its  position. 

These  symptoms  caused  the  practitioner  to  suspect  the  existence 
of  some  fluid,  which  it  was  necessary  to  evacuate  and  follow  with 
suitable  injections.  For  this  purpose,  the  cheek  was  drawn  aside, 
and  an  incision  made  into  the  bone  above  the  gum,  with  a  bistoury, 
enlarging  it  before  and  backward,  till  a  sufficient  opening  was  ob- 
tained, from  which  escaped  an  inodorous  mucous  fluid.  The  bone 
was  at  no  point  denuded  of  its  periosteum,  the  wound  was  dressed 
with  a  pledget  of  lint  saturated  with  spirits  of  wine,  and  the  next 
day  the  patient  was  better.  On  the  third  day  she  was  feverish,  the 
sinus  was  swollen  and  painful,  and  the  discharge  acrid  and  fetid. 
These  symptoms  were  controlled  by  proper  remedies,  and,  after 
twenty-four  days,  the  walls  of  the  sinus  were  nearly  restored  to 
their  normal  condition. 

The  canine  tooth  of  this  side  being  very  obliquely  situated,  it  was 
thought  proper  to  extract  it,  and  thereupon  followed  an  escape, 
through  its  socket,  of  fluid  contained  in  the  sinus,  though  the  tooth 
itself  seemed  perfectly  sound.  Through  this  orifice  injections  were 
made.  The  opening  made  in  the  external  wall  healed  promptly, 
without  any  exfoliation ;  in  six  months  the  tumor  entirely  disap- 
peared, and  the  patient  was  cured.  (From  Baron  Haller's  Collection 
of  Medico-Chirurgical  Theses.) 

The  translator  of  the  above  case,  in  commenting  upon  the  treat- 
ment, pointedly  remarks:  "One  cannot  fail  to  see  the  uncertainty, 
not  to  say  obscurity,  of  the  treatment  here  adopted.  Though  all 
the  teeth  were  carious,  and  their  extraction  was  plainly  indicated, 
an  incision  in  the  external  wall  of  the  antrum,  or,  more  correctly,  its 
destruction,  was  determined  upon.  The  result  we  see  in  the  symp- 
toms which  supervened  on  the  third  day,  which  were,  perhaps, 
hastened  by  the  spirits  of  wine.  We  have  here  a  canine  tooth  quite 
displaced  and  involved  in  the  tumor ;  yet  it  was  long  before  the  idea 
of  its  extraction  occurred,  though  the  subsequent  discharge,  through 
its  socket,  proved  how  advisable  it  would  have  been  at  the  com- 
mencement of  the  treatment.  In  this  way  the  time  of  cure  might 
have  been  shortened  by  half." 


422  ORAL  DISEASES  AND  SURGERY. 

Case  11.— Distention  with  Softening  of  the  External  Walls  of 

the  Sinus. In ,  says  this  same  surgeon,  I  was  consulted  in  the 

case  of  a  large  tumor  of  the  right  cheek.  The  external  wall  was 
much  distended  and  softened,  and  yielded  to  pressure,  upon  the  re- 
moval of  which  it  gave  a  sound  resembling  the  crushing  of  an  egg- 
shell. The  nose  was  turned  to  one  side  —  the  nostril  was  ob- 
structed — yet  the  patient  suffered  no  pain,  and  the  skin,  though 
distended,  preserved  its  natural  color.  On  examination  of  the 
mouth,  I  found  that  the  crowns  of  the  bicuspidati  and  molars  were 
destroyed  by  caries,  which  induced  me  to  advise  the  extraction  of 
their  persistent  fangs ;  the  patient  consenting,  this  was  immedi- 
ately done.  The  shock  occasioned  by  the  extraction  of  each  of  the 
fangs,  caused  a  portion  of  fluid  to  escape  from  the  sinus  through  the 
natural  opening ;  it  was  thin,  reddish,  saline,  and  inodorous,  and, 
in  all,  about  three  spoonfuls.  The  tumor  could  now  be  made  to  dis- 
appear by  pressure,  but  would  again  return  to  its  full  size.  Pressure 
caused  no  escape  of  fluid  through  the  nasal,  and  but  slight  through 
the  alveolar  opening,  which  was  at  the  bottom  of  the  first  molar 
socket,  and  large  enough  to  admit  the  finger. 

The  internal  membrane  of  the  sinus  was  entire,  except  at  the 
alveolar  opening;  through  this  I  made  injections  of  warm  water, 
strengthened  with  a  little  alcoholic  vulnerary  fluid.  The  next  day 
I  injected  the  sinus  repeatedly  with  a  decoction  of  agrimony*  and 
honey  of  roses,  meanwhile  not  neglecting  external  compression.  In 
fifteen  days  the  parts  returned  to  their  natural  condition,  all  crepitar 
tion  of  the  bone  ceased,  and  the  discharge  was  very  slight.  I  now 
had  recourse  to  stimulating  solutions.  On  the  second  day  the  dis- 
charge had  ceased,  and  the  alveolar  opening  was  reduced  to  a  mere 
fissure,  and  in  a  month  from  the  extraction  of  the  teeth  the  patient 
was  fully  restored. 

Case  III. — Periodontal  Abscess  affecting  the  Antrum. — A  patient 
was  brought  to  me  who,  for  more  than  three  months,  had  sufi"ered 
with  a  tumor  like  the  above,  on  the  right  side.  The  maxillary 
cavity  was  distended  to  a  level  with  the  orbital  margin ;  the  nose 
was  turned  to  one  side,  and  the  vault  of  the  palate  was  remarkably 
prominent.    I  removed  the  fangs  of  the  first  two  molars,  the  crowns 


*  A  mild  tonic  and  astringent.     An  injection  of  more  character  would  be 
as  follows : 

R.— Glycerin,  ^i; 

Tinct.  opii  camph.  ^ij ; 
Aqua  Cologn.  5iv.     M. 


ANTRUM   OF  HIGHMORE  AND   ITS  DISEASES.     423 

of  which  had  been  destroyed  by  caries,  and  which  I  believed  to  be 
the  immediate  cause  of  the  disease.  I  then  enlarged  the  opening  at 
the  bottom  of  one  of  the  sockets,  through  which  escaped  a  large 
quantity  of  a  serous  inodorous  fluid.  Pressure  upon  the  palate  and 
external  wall  caused  its  escape  through  both  the  alveolar  and  nasal 
opening;  this  compression,  together  with  suitable  injections,  soon 
terminated  the  disease. 

The  teeth  on  the  left  side  being  in  a  similar  condition,  their  re- 
moval was  urged ;  but  to  this  the  patient  would  not  consent.  In 
three  months  she  came  to  me  with  a  precisely  similar  swelling  of 
this  side,  which,  having  the  same  cause,  I  cured  in  the  same 
manner. 

Case  IY. — Abscess  of  the  Antrum  caused  by  a  Tooth. — The  fol- 
lowing very  interesting  and  instructive  case  is  from  the  practice  of 
Dr.  J.  D.  White,  and  was  reported  for  the  Dental  Cosmos  by  his 
son,  Horace  Meredith  White,  M.D.: 

"Mr.  S.,  aged  twenty  years,  light  complexion,  peculiar  whiteness 
of  the  skin,  a  characteristic  of  the  family,  had  been  complaining  for 
some  time  of  a  fetid  discharge  from  the  right  nostril ;  of  heat,  and  a 
sense  of  tension  in  the  right  superior  maxilla. 

"  He  applied  to  his  physician,  who  gave  him  a  wash,  with  the 
belief  that  the  parts  would  speedily  return  to  their  normal  condition, 
he  supposing  the  affection  to  be  merely  an  increased  discharge  de- 
pending on  a  slight  local  hyperaemia,  the  result,  perhaps,  of  the  bad 
state  of  the  weather  at  the  time.  The  parts,  however,  did  not  re- 
cover, the  discharge  became  much  more  fetid,  and  evidently  was 
principally  composed  of  unhealthy  pus,  though  it  was  not  as  copious 
as  it  had  been  previously ;  the  pain  was  not  severe,  but  the  heat  of 
the  parts  more  elevated,  and  the  sense  of  tension  increased.  The 
patient  was  irritable  and  pale  ;  the  heat  of  the  body  was  rather 
above  the  average  temperature.  This  was  the  condition  of  the  patient 
when  he  came  under  the  care  of  Dr.  W. 

"  Upon  examining  the  anterior  nares  nothing  could  be  discovered 
to  account  for  the  discharge  ;  the  mucous  membrane  being  a  little 
inflamed,  but  not  sufficient  to  occasion  it.  A  diseased  state  of  the 
antrum  was  suspected,  and  the  mouth  was  examined  to  ascertain  if 
a  diseased  tooth  could  be  the  cause.  The  second  molar,  upper  jaw, 
right  side,  w^as  unsound.  Part  of  the  crown  w^as  decayed  away  ;  the 
bulbous  portion  of  the  nerve,  and  the  filaments  of  the  buccal  roots, 
were  dead,  but  that  part  in  the  palatine  root  was  living,  and  occa- 
sioned the  patient  pain.     A  little  arsenical  paste  was  applied  to  de- 


424  ORAL  DISEASES  AND  SURGERY. 

II 
8troy  it.     No  sign  of  alveolar  abscess  was  present  in  it  or  any  other    | 
tooth.     The  next  day  the  nerve  in  the  palatine  fang  was  removed 
without  trouble ;  a  careful  iuispection  was  now  made,  and  important 
information  was  received.     Upon  examining  the  right  nostril  with    j 
a  speculum,  a  little  pus  was  seen  in  the  middle  meatus.    The  patient    I 
was  requested  to  incline  the  head  toward  the  left  side ;  he  did  so,    ! 
and  upon  looking  at  the  parts  again,  a  large  amount  of  pus  was 
found.     This,  together  with  the  facts  stated  already  in  this  paper, 
and  that  there  was  no  other  assignable  cause  of  the  discharge,  were 
deemed  sufficient  to  establish  the  diagnosis — abscess  of  the  antrum, 
caused  probably  by  the  unsound  second  molar  tooth. 

"  Extraction  was  advised  and  submitted  to.  Upon  the  removal 
of  the  tooth  no  pus  escaped.  A  probe  was  introduced  into  the  alve- 
olus previously  occupied  by  one  of  the  buccal  roots,  and  readily 
passed  on  into  the  antrum  ;  pus  now  followed  the  withdrawal  of  the 
instrument. 

"  The  cure  was  completed  on  general  principles." 

Dr.  White  concludes  the  description  of  his  case  by  remarking  a 
coincidence  which  it  will  not  be  at  all  amiss  to  repeat  here — a  coin- 
cidence which  could  only  have  been  alarming  enough  to  the  patient. 
The  gentleman  had  repeatedly  visited  a  horse  belonging  to  his  father, 
which  had  a  profuse  discharge  from  the  nose,  and  which  was  thought 
to  be  glanders.  The  horse's  malady  was  prior  to  that  of  the  pa- 
tient, and,  of  course,  could  only  have  caused  him  to  fear  that  he 
had  contracted  the  disease  from  it. 

Dropsy  of  the  Antrum. — This,  which  is  only  another  name  for 
mucous  engorgement,  is  not  unfrequently,  as  I  have  had  occasion  to 
observe,  the  result  of  a  reflected  chronic  periodontal  inflammation. 
In  such  cases,  we  have  the  analogue  of  similar  inflammation  in  the 
cavity  of  the  mouth ;  the  membrane  becomes  puffy  and  thickened, 
the  mucous  secretions  become  inspissated,  the  natural  opening  of 
the  sinus  (simply  through  this  thickening  of  the  mucous  membranes, 
the  folds  of  which  are  the  natural  outlet  of  the  cavity)  become  ob- 
literated. All  egress  being  closed,  the  result  is  not  difficult  to  sur- 
mise :  if  there  should  not  occur  atresia  of  the  occluding  membranes, 
and  no  correct  surgical  assistance  is  afforded,  there  must,  of  course, 
result  either  the  gradual  attenuation  of  the  weakest  portion  of  the 
parietes  of  the  cavity,  or  the  setting  up  of  active  and  severe  inflam- 
mation. If,  on  the  contrary,  the  natural  outlet  has  a  partial  restora- 
tion, it  is  not  at  all  unlikely  that  a  troublesome — and,  if  misunder- 
stood— a  tedious  and  unmanageable  puruloid  discharge  will  ensue : 


ANTRUM  OF  HIGHMORE  AND   ITS  DISEASES.     425 

this  being  the  result  of  a  continuance  of  the  cause  of  trouble.     Re- 
calling illustrative  examples  from  my  own  practice,  I  remember  par- 

!  ticularly  the  case  of  a  child  who,  previously  to  coming  under  my 
care,  had  been  treated  nearly  two  years  for  the  occasional  discharge 
of  muco-purulent  matter  from  the  left  nostril ;  the  child  was  of  bad 
temperament,  being  a  cross  of  the  bilio-lymphatic.       This  patient  I 

j  had  the  satisfaction  of  relieving  in  a  single  week,  the  treatment  being 

I  wholly  directed  to  the  dental  arch,  if  I  may  except  a  course  of  salt 
sheet-baths — continued  long  after  the  local  cure,  and  which  had  been 

i   directed  in  consideration  of  the  relaxed  condition  of  her  general 

I    system. 

i  The  relation  of  temperament  and  conditions  are  to  be  closely  con- 
sidered in  connection  with  these  diseases  of  the  antrum  ;  it  is,  of 
course,  far  from  being  every  one  who  is  troubled  with  a  bad  tooth, 
the  fangs  of  which  penetrate  the  cavity,  that  has  secondary  disease 
as  the  result.     I  have  just  now  under  treatment  a  patient  suffering 

j  from  necrosis  of  the  whole  roof  of  the  mouth,  the  result  of  a  syphi- 
litic cachexia,  the  exciting  cause  of  the  local  trouble  being  an  inci- 
sor tooth  anomalously  developed.  This  tooth,  the  extreme  point  of 
which  presented  just  back  of  the  incisive  foramen,  had  been  mistaken 
by  a  practitioner  for  the  point  of  a  sequestrum,  and  being  worked 
and  cut  at,  periostitis  had  developed ;  and  when  the  dead  bone,  which 
is  the  result,  is  ready  to  come  away,  I  am  sure  I  shall  find  both  antra 
exposed.* 

Without  such  predisposing  cause,  it  is  evident  that  this  extensive 
disease  would  never  have  been  excited.  It  is  the  same,  as  in  every 
direction  of  surgical  practice — one  man  receives  a  wound,  a  cut  per- 
haps on  the  face,  and  it  troubles  him  so  little  that  he  scarcely  stops 
for  a  moment  his  work  to  examine  the  injury  ;  another  receives  pre- 
cisely the  same  kind  of  a  wound,  and  in  a  week  he  is  dead  from  ery- 
sipelas. 

A  purulent  condition  of  the  secretions  of  the  antrum  may  be 
viewed  as  one  would  view  a  gonorrhoea ;  indeed,  Mr.  Bell,  the 
English  author,  describes  the  conditions  as  being  similar.  "Both 
diseases,"  he  says,  "  consisting  equally  of  an  altered  secretion ;  in 
the  one,  of  the  pituitary  membrane,  and  in  the  other  of  the  muscular 
lining  of  the  urethra,  which,  in  neither  instance,  possesses  any  of 


*  This  proved  to  be  the  case  ;  the  lost  process  being  now  replaced  by  an  ob- 
turator.    For  the  making  of  such  an  instrument,  see  '^Palatine  Defects." 


426  ORAL  DISEASES  AND  SURGERY. 

the  characteristics  of  abscess,  though  the  matter  in  both  is  puru- 
lent." 

Certainly,  if  we  allow  for  some  differences,  as  influenced  by  cause 
and  location,  the  description  of  the  one  would  very  well  answer  as 
the  description  of  the  other.  In  both  we  have  the  same  perverted 
secretion,  the  same  molecular  change,  the  same  sthenic  and  asthenic 
modifications. 

As  a  gonorrhceal  discharge  is  always  preceded  by  certain  inflam- 
matory conditions,  and  as,  after  the  subsidence  of  the  acute  attack, 
the  discharge  may  long  continue  profuse,  or,  on  the  contrary,  may 
decline  to  a  scarcely  perceptible  minimum  ;  so,  in  antral  puruleney, 
must  we  have  the  associated  inflammation,  and  may  have  the  pro- 
fuse or  limited  secretion. 

In  antral  diseases,  however,  as  may  be  readily  inferred,  very 
much  depends  on  the  nature  and  associations  of  the  secretion.  A 
profuse  discharge,  with  closure  of  the  orifice  of  the  cavity,  must 
necessarily  entail  the  most  untoward  consequences ;  the  walls  of 
the  cavity  will  attenuate  until  (unless  surgically  relieved)  the  weak- 
est point  will  give  way,  the  rupture  being  most  apt  to  occur,  either 
within  the  orbit,  or  the  mouth.  Not  unfrequently,  however,  this 
weakest  portion  seems  to  be  the  canine  fossa,  and  the  opening  has 
occurred  at  the  tuberosity.  My  own  experience  would  lead  to  the 
inference  that  the  hard  palate  is,  by  far,  the  most  common  point 
at  which  the  matter  seeks  egress.  You  will  see  a  tumor  bulging 
out  from  one  side  of  the  mesial  line,  and  which  advances  more 
or  less  rapidly,  until  fluctuation  becomes  very  distinct.  A  sign 
diagnostic  of  this  class  of  tumors  is,  that  its  internal  boundary  is 
apt  to  be  quite  abrupt,  and  does  not  pass  the  line  midway  to  the 
mesial  division.  The  establishment  of  a  fistule  relieves  it  at  once 
of  the  sense  of  distention,  and  if  it  has  formed  in  a  convenient 
place,  as  within  the  mouth,  the  patient  may  feel  disposed  to  con- 
gratulate himself  on  having  come  to  a  sufficient  cure.  Unfortu- 
nately, however,  in  the  majority  of  cases,  this  satisfaction  is  of 
short  continuance ;  for,  independent  of  the  fact  that  the  disease  at 
once  takes  on  the  chronic  form,  making  the  sufferer  an  object  of 
disgust  to  those  with  whom  he  is  brought  into  immediate  contact 
— the  fetor  of  the  discharge,  under  some  circumstances,  being  really 
unbearable ;  yet,  also,  is  the  undue  retention  of  the  secretion  within 
the  cavity  such  a  source  of  irritation  to  the  parts  that,  not  unfre- 
quently, the  most  serious  lesions  result.  In  some  instances,  the 
whole  of  the  bones  of  the  face  are  destroyed. 


ANTRUM  OF  HIGHMORE  AND   ITS  DISEASES.     427 

The  causes  influencing  retention  of  these  secretions  are  twofold : 
First,  the  external  wound  is  apt  to  heal,  and  to  continue  impervious 
until  an  increase  of  the  secretion  induces  sufficient  pressure  to  cause 
its  absorption,  as  in  any  case  of  abscess.  In  the  second  place,  the 
passage  is  blocked  up  by  flocculi  within  the  cavity. 

Puruloid  secretion  in  the  antrum  may,  from  the  onset,  be  of  so 
I  limited  a  character  that — like  secretions  in  certain  of  the  ovarian 
cysts — years  may  pass  before  marked  inconvenience  results.  I  am 
acquainted  with  a  case,  that  of  Mr.  C ,  late  an  eminent  mer- 
chant of  this  city,  in  whom,  after  five  years  of  great  mental  and 
physical  suffering,  a  disease  of  the  antrum,  supposed  to  be  malig- 
nant, was  found  to  be  nothing  but  simple  muco-puruloid  engorge- 
ment depending  upon  a  dead  tooth.  In  this  case  the  trouble  had 
commenced  with  a  feeling  of  heaviness  and  oppression  in  the  body 
of  the  jaw;  the  parts  had  gradually  enlarged  until  finally  there 
was  distention  of  the  cheek  to  the  size  of  a  large  fist,  the  eye 
being  thrown  entirely  out  of  position  from  the  rising  of  the  roof  of 
the  antrum.  Much  treatment  had  been  given  the  case  without  the 
slightest  accruing  benefit.  No  attention,  however,  had  been  directed 
to  the  dental  arch — the  teeth,  although  the  patient  was  sixty  years 
of  age,  being  apparently  in  the  most  perfect  condition. 

The  result  of  this  case  was  the  diagnosis,  on  the  part  of  a  surgeon 
to  whom  he  finally  applied,  of  a  dead  nerve  in  one  of  the  bicuspid 
teeth  ;  the  organ,  although  as  healthy-looking  as  any  of  its  fellows, 
responded  to  the  stroke  of  an  instrument  in  the  manner  as  described 
in  the  chapter  on  Alveolar  Abscess  ;  this  tooth  was  extracted,  and  in 
six  months  the  health  of  the  patient  was  perfectly  restored. 

A  circumstance  connected  with  the  extraction  of  the  tooth  in  this 
case  offers  an  example  of  practice  of  which  it  is  well  not  to  lose 
sight.  The  practitioner  who  related  to  me  the  circumstances  of  the 
case  informed  me  that  he  expected  to  find  associated  with  the  tooth 
fang  a  pyogenic  membrane,  and  to  have  the  extraction  followed  by 
a  gush  of  pus,  in  both  of  which,  however,  he  was  disappointed. 
The  fang  was  clean,  and  the  blood  which  followed  the  operation 
had  nothing  peculiar  about  it.  Not  to  be  thus  balked,  he  passed  a 
probe  up  the  alveolus  of  the  extracted  tooth,  which,  meeting  a  resist- 
ing yet  yielding  body,  he  punctured  in  the  direction  of  the  antrum ; 
the  withdrawal  was  followed  by  a  profuse  purulent  discharge.  This 
resisting  body  may  be  simply  flocculi,  as  alluded  to,  or  it  may  be 
the  mucous  membrane  proper  to  the  parts — most  likely  it  Avould  be 
found  the  latter,  for  we  are  to  remember  that  it  is  not  alveolar  or 


428  ORAL  DISEASES  AXD  SURGERY. 

antral  abscess  with  which,  in  these  cases,  we  are  dealing,  but  simply 
what  might  be  termed  a  mucitis,  and,  of  course,  a  break  in  the  con- 
tinuity of  the  membrane  is  not  necessarily,  to  be  looked  for.  The 
practitioner,  in  this  case,  only  approximated  to  the  exact  condition ; 
he  thought,  evidently,  that  the  trouble  was  tooth  abscess  discharg- 
ing itself  into  the  sinus,  whereas  (while  the  treatment  was  perfectly 
adapted  to  the  requirements)  the  case  was  one  of  simple  mucous  or 
muco-puruloid  engorgement,  the  result  of  reflected  irritation. 

The  diagnosis  of  mucoid  and  puruloid  engorgement  of  the  antrum 
is,  as  a  rule,  not  difficult  to  make  out.  At  first  there  is  inflammation, 
and  this,  as  suggested,  is  found  most  likely  to  have  origin  about  the 
teeth.  As  the  trouble  advances,  the  patient  begins  to  complain  of  a 
sense  of  heaviness  about  the  body  of  the  cheek.  If  the  secretion 
is  active,  there  will  be  much  pain,  sometimes  sharp  in  character,  but 
more  frequently  heavy  and  unbearably  dull.  In  all  chronic  perio- 
dontal inflammation,  we  have  this  same  dull  pain,  but  then  it  differs 
from  the  pain  of  engorgement  in  being  confined  to  the  alveolar  arch; 
in  this  latter  trouble  the  greatest  pain  is  found,  I  think,  associated 
with  the  floor  of  the  orbit,  which,  as  will  be  remembered,  makes  the 
roof  of  the  antrum.  At  length,  as  the  secretions  accumulate,  the 
parietes  of  the  cavity  begin  to  attenuate  and  expand.  The  tumor 
now  forming  may  be  distinguished  from  others — first,  by  the  his- 
tory of  the  case ;  second,  by  dryness  of  the  nares  of  the  affected 
side,  the  result  of  the  closure  of  the  orifice  of  the  antrum ;  third, 
by  the  gradual  and  regular  enlargement ;  fourth,  by  the  non-asso- 
ciation of  the  integuments  of  the  cheek ;  and,  fifth,  by  the  fluctua- 
tion which  it  will  finally  yield. 

To  treat  successfully  such  a  trouble,  we  have  only  to  search  out 
the  source  of  offense,  and,  where  it  is  possible,  remove  it.  If  this 
should  prove  to  be  a  tooth,  we  may,  if  necessary,  secondarily  treat 
the  antrum  through  the  alveolus.  Where  the  trouble  is  thus  of 
strictly  local  origin,  we  shall  find  that  we  need  to  do  very  little 
more  than  employ  daily  some  stimulating  injection:  diluted  tinc- 
ture of  iodine  is  a  favorite  M'ith  me.  Where  the  acrid  character 
of  the  retained  secretion  has  provoked  degenerating  ulcers,  I  have 
obtained  the  very  happiest  eflects  from  weak  injections  of  chloride 
of  zinc. 

If,  on  the  contrary,  such  bad  conditions  of  the  antrum  be  associ- 
ated with  constitutional  causes,  I  need  not  suggest  that  such  causes 
must  have  our  attention.  In  these  latter  cases,  however,  where  the 
cure  promises  to  be  tardy,  we  may  give  to  a  patient  complete  relief, 


ANTRUM  OF  HIGHMORE  AND  ITS  DISEASES.     429 

locally,  by  making  an  opening  into  the  antrum,  and  keeping  it  patu- 
lous by  means  of  a  cotton  tent;  this,  combined  with  the  daily  em- 
ployment of  such  injections  as  may  seem  indicated,  will  be  found  to 
yield  most  decided  benefit. 

Concerning  abscess  proper  of  the  antrum,  I  think  it  may  be  set 
down  as  the  rarest  of  rare  diseases.  Bell  and  Bordenhave  each 
mentions  a  case.  Abscesses,  described  so  frequently  as  occurring  in 
this  cavity,  will,  I  think,  commonly  be  found  to  have  their  origin  in 
the  alveolar  border,  and  if  treated  as  any  ordinary  case  of  alveolar 
abscess,  will  generally  at  once  succumb.  (See  chapters  on  Alveolar 
Abscess,  and  Anomalies  of  Dentition.) 

"  While,"  says  Dr.  Richardson,  "  we  cannot  trace  out  the  nature 
of  that  condition  of  the  blood  which  gives  rise  to  purulent  forma- 
tions, we  are  informed  by  observation  of  the  external  conditions 
which  foster  it.  We  learn  that  the  pus-producing  disposition  is  an 
indication  of  deterioration  of  blood.  We  see  that  when  the  system 
is  enfeebled,  whether  by  diathesis  hereditarily  supplied,  as  by  the 
strumous  diathesis — whether  by  epidemic  influences,  or  whether  by 
deprivation  of  nitrogenous  food,  or  the  inhalation  of  bad  air — that 
under  these  circumstances  the  tendency  to  purulent  formations  in 
local  structures  is  marked,  and  that,  in  extreme  instances  of  the  kind 
named,  the  act  of  suppuration  may  take  its  absolute  origin  from 
blood  thus  depressed. 

"  Hence  we  have  reduced  almost  to  a  principle  in  medicine,  the 
saying,  that  suppurative  tendency  is  a  sign  of  an  impaired  or  viti- 
ated nutrition.  Hence,  also,  we  reason  in  speculative  argument, 
that  pus  is  blood  transformed  into  a  lower  form  of  organization,  and 
we  adduce,  in  evidence  of  this  view,  that  the  purulent  fluid  is  in- 
capable of  organic  construction,  and  that  animals  in  which  the  respi- 
ration, the  circulation,  and  the  animal  temperature  are  more  than 
ordinarily  active,  the  formation  of  pus,  even  in  an  open  wound,  is 
an  occurrence  almost  unknown." 

These  remarks,  from  the  lectures  of  Dr.  Richardson,  cannot  fail 
in  being  suggestive;  they  have  indeed  much  meaning;  but  I  must 
be  permitted  to  suggest,  to  the  student  reader,  at  least,  that  their 
signification  is  limited.  Puruloid  conditions  are,  without  doubt, 
and  as  the  rule,  perhaps,  indications  of  asthenia ;  but  it  would  be 
very  Avrong  indeed  to  jump  from  such  data  to  the  conclusion  that 
every  puruloid  disease  requires  treatment  from  the  constitutional 
stand-point,  and  particularly  will  this  hold  good  as  the  diseases  of 
the  antrum  are  concerned. 


430  ORAL  DISEASES  AND  SURGERY. 

All  diseases  should  be  treated  on  princiijle  ;  M.  Ricord,  as  will  be 
recalk'd  by  many  of  my  readers,  has  a  favorite  prescription  for  gou- 
orrhceal  purulency,  which  runs  as  follows : 

B. — Pulv.  cubebae,  ^vi. 
Ferri  carb.  ^iij.  M. 

Now,  anybody  can  understand  that  such  a  combination  would 
most  naturally  act  well  on  a  debilitated  system  ;  and  I  should  sup- 
pose it  would  be  a  most  happy  prescription  for  half  the  roues  of 
Paris.  Where  applicable,  it  would  answer  as  well  for  the  puruloid 
antrum.  I  remember,  during  the  past  summer,  treating  a  gentleman 
for  a  gonorrhceal  difficulty,  which  he  had  contracted  almost  immedi- 
ately after  my  getting  him  over  an  attack  of  syphilis.  I  treated  this 
patient  locally  over  six  weeks,  the  discharge  constantly  increasing 
in  quantity.  At  the  expiration  of  this  period  I  put  him  upon  co- 
paiba, tinct.  of  iron  and  quinia,  and  sent  him  to  the  seaside  for  a  few 
weeks.  The  discharge  at  once  began  to  diminish,  and  after  the 
eighth  day  disappeared  entirely.  A  success  of  this  kind  would  not, 
however,  lead  to  the  inference  that  every  man  afflicted  with  a  puru- 
lent discharge  should  be  treated  with  tonic  stimulants.  On  the 
contrary,  I  have  had  the  opportunity  of  prescribing  very  frequently 
for  this  condition — gonorrhoea.  Yet  it  is  seldom  that  indications 
have  seemed  to  me  to  call  for  anything  more  than  a  strictly  local 
treatment;  at  any  rate,  I  have  generally  succeeded,  happily  and 
quickly,  in  getting  the  patients  over  their  trouble. 

On  a  previous  page  it  was  suggested  that  puruloid  conditions  of  the 
antrum  had  origin  chiefly  from  two  directions :  first,  from  diseased 
teeth ;  second,  from  constitutional  disturbance,  manifesting  itself  in 
the  mucous  tissue.  It  was  also  desired  to  convey  the  inference  that 
where  the  fault  was  markedly  in  the  first  of  these  directions,  the 
practitioner  would  err  on  the  right  side,  if,  in  his  first  consideration 
of  the  case,  he  should  incline  to  look  upon  the  tooth  only  in  the 
light  of  an  exciting  cause,  searching  farther  for  what  might  be  the 
predisposing  condition.  It  is,  however,  to  be  inferred  that  lesions 
of  the  cavity  may  exist,  and  yet  constitutional  conditions  have 
really  nothing  to  do  with  them,  and  in  the  treatment  need  not  at 
all  to  be  taken  into  the  account. 

As  a  line  in  practice,  however,  running  between  these  two  con- 
ditions, I  may  allude  to  the  fact  of  having  met  cases  where  inference 
of  constitutional  association  seemed  most  marked,  yet,  without  a 
resort  to  other  than  local  treatment,  I  have  soon  cured  my  patient. 


ANTRUM   OF  HIGHMORE  AND  ITS  DISEASES.     431 

These  are  the  kind  of  cases  in  which  the  medical  man  must  feel  his 
way ;  if  he  be  an  observer,  it  is  not  likely  that  more  than  a  week 
will  pass  without  yielding  him  just  conclusions. 

Coming  now  to  the  investigation  of  cases  where  the  cause  is 
to  be  found  alone  in  some  cachexia,  we  have  only  to  refer  back 
to  the  general  features  of  disease  as  manifested  on  mucous  mem- 
branes. 

The  most  common,  and  indeed  not  very  unfrequent  cause  of  en- 
gorgement of  the  antrum — particularly  mucous  engorgement — is 
simple  catarrh  of  the  Schneiderian  membranes.  The  patient  takes 
a  cold,  the  excitement  expends  itself  about  the  nares ;  by  simple 
continuity  of  structure  the  lining  membrane  of  the  sinus  becomes 
vascularly  excited ;  perhaps  the  duplication  at  the  orifice,  because 
of  greater  nearness  to  the  central  ring  of  inflammation,  becomes  con- 
gested to  such  extent  as  to  close  the  opening ;  thus  we  have  the 
elements  for  engorgement,  and  the  mucus  thus  confined  will,  if  not 
vented,  sooner  or  later  act  as  such  a  source  of  irritation  that  it  will 
become  to  the  membrane  of  the  cavity  almost  precisely  what  the 
virus  of  gonorrhoea  becomes  to  the  same  character  of  membrane 
lining  the  urethra.  Trouble  from  this  cause  is,  however,  generally 
so  slight  and  so  quickly  over  that  it  is  seldom  prominently  marked, 
either  to  patient  or  practitioner. 

The  symptoms  designating  this  condition  are,  first,  simple  vascu- 
lar excitement  of  the  membrane  lining  the  nares,  accompanied  with 
increase  of  mucus. 

As  the  grade  of  inflammatory  action  advances  to  complete  con- 
gestion, the  excess  of  mucus  associated  with  the  immediately  pre- 
ceding stage  is  succeeded  by  a  most  uncomfortable  deficiency  in  the 
secretion. 

This  dryness  is  associated  with  all  nasal  inflammations  of  ad- 
vanced grade,  but  when  the  trouble  is  to  implicate  the  antrum,  it  is 
even  specially  marked.  A  single  moment's  consideration  of  the 
parts  makes  this  very  plain :  the  nares  are  the  natural  outlets  for 
the  antral  secretions;  in  ordinary  Schneiderian  catarrh  the  exten- 
sive secretory  surfaces  of  the  antra  are  comparatively  unaSected :  of 
course  they  serve  to  lubricate,  to  a  greater  or  less  extent,  the  pas- 
sages. When,  however,  the  grade  of  inflammation  is  of  suflicient 
extent  to  congest  the  duplicatures  of  membrane  which  form  the  nasal 
outlets,  then,  because  of  the  retention  of  the  mucus,  the  extreme 
dryness  is  induced.  This  excessive  dryness  may  be  said,  therefore, 
to  offer  the  first  diagnostic  sign  of  antral  engorgement  from  simple 


432  ORAL  DISEASES  AND   SURGERY. 

catarrh  From  this  point  the  disease  advances  or  declines.  If  it 
declines,  the  trouble  may  have  proved  of  such  trifling  inconvenience 
as  scarcely  to  have  attracted  the  attention  of  practitioner  or  patient. 
If  on  the  contrary,  it  advances,  the  patient  will  soon  be  made  con- 
scious of  the  advancing  engorgement  by  a  sense  of  growing  heavi- 
ness in  the  cheek,  attended  by  pain  of  a  dull,  sluggish  character. 
The  progress  of  the  disease  from  this  condition  is  precisely  the  same 
as  that  described  as  accruing  from  dental  troubles. 

Treatment. — This  is  to  be  conducted  on  general  principles. 
Where  the  disease  is  seen  in  its  incipient  stage,  it  will,  perhaps,  be 
found  unnecessary  to  do  more  than  administer  a  saline  cathartic;  or, 
what  I  have  found  a  most  satisfactory  treatment,  is  to  administer  to 
the  patient  at  bedtime  one-sixth  or  one-quarter  of  a  grain  of  sulphate 
of  morphia  dissolved  in  an  ounce  of  the  liq.  ammonite  acetatis.  This 
latter  treatment  will  seldom  be  found  to  fail  in  breaking  up  these 
limited  congestions. 

Where,  however,  the  disease  has  advanced  to  engorgement,  and 
the  antrum  is  found  to  be  enlarging,  it  may  be  necessary,  in  order 
to  insure  against  even  more  serious  lesions,  that  treatment  shall  be 
directed  immediately  to  the  cavity.  To  accomplish  this,  extract  the 
second  molar  tooth,  and  penetrate  the  cavity  through  the  alveolus  of 
the  palatine  fang ;  in  this  way  such  medication  as  may  seem  indi- 
cated may  be  readily  employed  ;  indeed,  for  a  cure  it  may  be  only 
necessary  to  keep  patulous  the  wound,  leaving  the  rest  to  nature,  or, 
if  there  should  seem  a  lack  of  vital  force,  I  do  not  think  a  much  hap- 
pier stimulant  can  be  employed  than  the  tinct.  of  iodine. 

Furuncular  Epidemics. — It  will  be  found,  I  think,  the  conclusion 
of  every  one  who  has  observed  in  the  direction,  that  during  the  ex- 
istence of  furuncular  epidemics,  mucous  and  purulent  engorgements 
of  the  antrum  are  most  common.  This  is  not  strange,  if  we  con- 
sider the  epidemic  condition  in  the  light  of  an  exciting  cause  alone, 
for  in  no  single  instance  where  my  attention  has  been  called  in  such 
direction,  have  I  been  unable  to  discover  a  predisposing  cause  in  a 
dead  or  diseased  tooth.  The  same  condition  of  things  exists  in  re- 
gions where  the  intermittents  are  endemic.  All  the  odontalgias  and 
cephalalgias  of  such  a  country  are  apt  to  be  quotidian,  tertian,  or 
quartan.  Furuncle  is  a  condition  associated,  it  would  seem,  with 
some  derangement  of  the  digestive  or  cutaneous  functions.  When 
epidemic,  it  would  be  in  proof  that  a  condition  existed  adverse  to 
the  performance  of  certain  physiological  functions.  With  the  exist- 
ence of  a  predisposing  cause  of  disease  about  the  antrum,  it  is  not 


j  ANTRUM   OF  HIGHMORE  AND   ITS  DISEASES.     433 

j  at  all  strange  that  the  addition  thereto  of  an  exciting  cause  should 
at  once  increase  the  effect  of  the  irritant  even  to  the  production  of 
active  disease, — and  such,  in  truth,  is  the  case :  the  patient  escapes 
the  purulency  of  boils,  but  he  has  purulency  of  the  antrum. 

Treatment. — This  I  need  scarcely  refer  to:  it  consists,  imprimis, 
in  removing  the  source  of  local  irritation  ;  secondly,  in  correcting 
the  constitutional  disturbances. 

Scorbutus. — This  diathesis,  as  may  be  inferred,  predisposes  to  an- 
tral purulency  and  ulceration.  To  understand  the  local  condition 
thus  induced,  it  would  be  only  necessary  to  examine  the  gums  in  an 
individual  so  afflicted ;  the  condition  of  the  antrum  is  akin  to  the 
condition  of  the  mouth.  The  treatment,  to  be  successful,  must  be 
from  the  constitutional  stand-point.  If  injection  of  the  cavity  seems 
indicated,  it  must  be  gotten  at  as  before  directed,  or  a  canula  can  be 
passed  into  it  through  the  natural  opening  in  the  middle  meatus  ;  the 
latter  is,  however,  diflBcult,  and  therefore  liable  to  objection. 

TJie  Exanthemata  are  said  to  associate,  not  unfrcquently,  their 
sequelas  with  this  cavity.  Treatment  thus  demanded  could  need  no 
special  consideration, — it  would  be  a  treatment  founded  on  general 
principles. 

The  ATercurial  Diathesis. — I  have  before  referred  to  the  troubles 
of  the  cavity  thus  provoked.  Mercuiy  holds  a  double  pathological 
relation  to  the  antrum ;  it  predisposes  from  its  constitutional  rela- 
tions, and  actively  and  locally  excites,  through  the  periosteal  inflam- 
mation it  excites  in  the  alveoli  of  the  teeth.  (The  same  I  should 
also  have  remarked  of  scurvy.) 

Treatment. — The  indications  here  are  twofold.  Resolve,  if  pos- 
sible, the  inflammation  about  the  teeth  (see  chapter  on  Alveolar 
Abscess),  and  eliminate  the  mercury  from  the  system.  The  chlorate 
of  potash  and  the  common  muriate  of  soda  are  valuable  medicines  in 
this  direction ;  the  latter  I  frequently  employ,  and  with  marked 
success. 

Syphilis. — This  is  a  disease  which  it  might  be  inferred  would,  of 
course,  have  an  afiinity  for  such  mucus-lined  surfaces  as  the  antrum. 
Now  mine  may  be  a  singular  experience,  but  in  contradiction  of 
many  authors  who  have  written  on  the  subject,  I  must  say  that,  with 
the  wide  scope  afforded  by  such  a  hospital  as  Blockley  (where,  for 
over  a  year,  I  gave  the  study  of  the  venereal  disease  the  closest  at- 
tention), I  was  unable  to  find  a  single  case  of  diseased  antra  which 
could  with  justice  be  attributed  to  the  cachexia.    As  I  remarked  on 

28 


434  ORAL  DISEASES  AND   SURGERY. 

a  previous  page,  I  have  met  cases  where  the  origin  has  been  traced 
for  me  in  such  a  direction ;  and  I  will  not  deny  that,  in  some  cases, 
this  origin  may  be  justly  so  traced ;  but,  in  every  case  that  I  have 
seen,  the  mercury  administered  for  the  cure  of  the  syphilis  has 
seemed  to  me  as  having  much  more  to  do  with  the  condition  than 
any  dyscrasis  induced  by  the  virus.  (See  this  subject  continued  in 
chapters  on  Ozsena  and  Tumors.) 


CHAPTER    XXX. 

NEURALGIA. 

i 

I  The  terra  neuralgia  is  from  the  Greek  roots  veupov,  a  "nerve," 
and  (ilyoq,  "pain."  It  signifies  a  condition,  or  an  effect,  and  not  a 
jcause;  or  if  this  definition  is  not  absolutely  a  correct  one,  the  ex- 
Iceptions  to  the  rule  it  would  form  are,  I  am  convinced,  exceedingly 
jrare.  For  such  reasons  it  is,  as  commonly  employed,  a  very  ill 
and  deceptive  term,  expressing  a  condition,  about  as  the  term  sup- 
puration would  convey  a  definite  idea  of  the  phenomena  of  inflam- 
mation. 

Neuralgia,  as  the  word  has  been  made  to  have  definite  applica- 
tion, refers  to  paroxysmal  pains,  localized  or  metastatic,  presenting 
no  manifestation  of  any  lesion  at  the  seat  of  pain  outside  of  the  single 
phenomenon. 

The  pains  of  neuralgia  are  mostly,  although  not  exclusively,  acute 
in  character,  are  confined  to  the  tract,  or  to  the  periphery  of  a  cer- 
tain nerve,  remit,  or  more  commonly  fully  intermit,  are  alone  ac- 
companied with  tenderness  of  the  part  involved  when  an  accidental 
associate  lesion  may  exist,  or  when  an  irritation  is  so  severe,  or  has 
been  so  long  continued,  as  to  have  reacted  on  the  neighboring  vas- 
cular system. 

When,  then,  a  practitioner  has  his  attention  directed  to  a  seat  of 
pain  without  apparent  lesion,  the  matter  of  first  importance  is  an 
appreciation  of  its  cause.  To  say  that  such  a  one  has  neuralgia, 
and  to  treat  him  with  nervines,  is  to  say  just  nothing,  and  to  do 
nothing,  except  indeed  by  accident.  A  first  duty  is  to  search  for  a 
cause,  and  if  discoverable,  remove  it,  if  that  be  possible.  Now  these 
causes  of  neuralgia  are,  as  I  shall  further  on  show,  sometimes  very 
evident,  and  very  easy  of  removal ;  and  it  will  be  seen  by  the  illus- 
trations I  shall  offer,  that  one,  from  lack  of  observation,  utterly  fails 
in  giving  a  relief  very  easily,  and  naturally,  afforded  by  another. 

Rheumatism  and  neuralgia  are  frequently  confounded ;  but  bow 
do  the  conditions  disagree  ?     Rheumatism  is  always  accompanied 

(435) 


436  ORAL   DISEASES  AND   SURGERY. 

with  va?;iMiIar  perversion,  the  pain  is  not  distinctly  localized,  but  is 
diffuscul  over  apart  involved;  it  is  a  soreness,  as  a  general  thing, 
rather  than  a  sharp,  acute,  concentrated  pain.  Movement  aggra- 
vates this  soreness,  changes  in  temperature  aifect  it ;  it  is  not  parox- 
ysmal, although  it  may  be,  and  generally  is,  remitting;  in  short,  it 
has  a  history,  and  this  history  is  not  difficult  to  read. 

Gout  is  another  constitutional  condition  occasionally  mistaken 
fur  neuralgia;  but  such  a  mistake  should  not  occur,  for  here,  too,  is 
a  history.  Gout  occurs  in  the  high,  indolent  liver;  it  is  decidedly 
inflammatory  in  its  local  manifestations.  It  attacks  in  preference 
the  small  joints;  it  is  accompanied  by  oedema,  by  congestion,  and 
by  enlargement  of  the  veins ;  if  it  is  metastatic,  the  seat  of  transfer 
presents  like  vascular  phenomena  with  the  original  inflammation. 

But  is  there  not  a  condition,  a  disease,  which  is,  or  might  be, 
termed  neuralgia ;  as,  for  example,  gout  is  a  disease  with  an  indi- 
viduality, or  rheumatism  is  a  disease.  If,  without  being  influenced 
by  other  than  my  own  observations,  I  were  to  answer  this  question, 
I  should  incline  to  say  there  is  not;  and  my  reasons  for  the  denial 
would  lie  in  the  fact  that  I  have  in  one  way  or  another  become 
conversant  with  so  many  cases  which  have  stubbornly  resisted  a 
long  course  of  treatment  founded  on  an  abstract  neuralgic  theory, 
but  which  have  rapidly  and  readily  yielded  on  the  discovery  and 
removal  of  some  true  lesion  of  which  the  pain  was  simply  a  sympa- 
thetic connection, — as,  for  instance,  otalgia,  hemicrania,  or  even 
sciatica,  from  an  exposed  tooth  pulp,  from  a  splinter  of  foreign  sul)- 
stance,  or  from  the  pressure  of  an  exostosis.  It  is  certainly  true 
that  there  is  a  class  of  persons  which  might  be  termed  neuralgic ; 
these  do  not  belong  strictly  to  what  is  called  the  nervous  tempera- 
ment, but  are  the  anaemic  and  prostrated.  A  plethoric  temperament 
disposes  to  inflammation,  but  plethora  is  not  inflammation,  it  is  only 
a  predisposition ;  the  nervous  temperament  is  only  a  pi*edisposition. 
One  could  not  deny  that  cases,  called  neuralgia,  and  treated  with- 
out ideas  of  a  definite  lesion,  do  very  frequently  get  well ;  but  has 
not  the  indication  been  accidentally  met,  just  as  with  the  Dewee's 
carminative  we  treat  the  restless  child  and  cure  it  without  definite 
idea  of  the  ailment,  having  in  a  single  medicine  the  requirement 
of  various  conditions  ?    I  think  this  is  so. 

If  neuralgia,  then,  is  simply  a  phenomenon,  simply  the  expression 
of  an  immediate  or  distant  lesion,  the  preliminary  treatment  lies  in  a 
search  after  a  cause.  But  is  this  cause  always  evident  ?  It  truly  is 
not,  at  least  to  our  present  acquirements ;  but  still  it  exists,  and 


NEURALGIA.  437 

failing  to  discover  it,  we  are  compelled  to  desert  principles  and  ex- 
perimentally treat  with  the  hope  of  an  accidental  success. 

Are  there  predisposing  causes  of  pain  radiation?  Undoubtedly 
there  are,  and  these  may,  and  always  should,  receive  a  proper  de- 
gree of  attention,  as,  in  guarding  against  them,  it  might  be  that  the 
proper  lesion  would  not,  in  itself,  be  sufficient  to  inaugurate  or  main- 
tain the  neuralgia.  Thus,  of  the  exciting  causes,  a  damp,  cold  at- 
mosphere is  probably  one  of  the  most  potent.  Fatigue,  overexcite- 
ment,  excess  in  drinking,  poor  diet,  the  too  free  use  of  coffee  or  tea, 
loss  of  sleep,  costiveness,  diarrhoea, — in  short,  any  and  everythino- 
which  interferes  with  the  easy  and  proper  performance  of  functional 
life. 

In  miasmatic  neighborhoods,  neuralgia  frequently  assumes  the 
periodic  type,  evidently  influenced  by  the  malaria.  And  it  is  with- 
out doubt  true,  that  the  exhibition  of  quinine  will  and  does,  not  uu- 
frequently,  cure  such  cases;  whether  this  is  because  the  medicine 
controls  the  full  and  complete  cause  of  the  trouble,  or  only  removes 
an  exciting  cause,  which,  in  its  absence,  gives  to  nature  the  mastery, 
I  scarcely  know,  it  being,  without  doubt,  certain  that  it  is  not  by 
any  means  always  the  case,  that  in  the  destruction  of  the  periodicity 
the  pain  is  removed. 

Syphilis  is  another  of  the  exciting  causes  of  neuralgia.  I  hav^e 
known  a  patient  have  great  pain  from  diseased  teeth,  which  could 
be  held  completely  under  control,  although  not  cured,  by  iodide  of 
potassium, — proved  to  be  from  the  teeth,  as  with  the  subsequent 
removal  of  these  organs  the  trouble  disappeared. 

To  epitomize  the  subject,  we  might  say  that  in  a  state  of  health 
the  nervous  system  represents  the  poised  balance :  it  is  neither  ex- 
cited nor  depressed ;  it  works  in  entire  harmony  with  its  require- 
ments. Apply  now  a  source  of  irritation,  and  this  harmony,  or 
balance,  is  destroyed.  According  as  the  amount  and  extent  of  irri- 
tation, so  is  the  amount  and  extent  of  derangement.  Life,  says 
Bichat,  rests  upon  the  tripod  of  innervation,  respiration,  circula- 
tion. Whatever  affects  one  of  these  legs  affects  the  whole  body. 
To  appreciate  the  phenomena  of  neuralgia  is,  then,  to  appreciate  the 
phenomena  of  irritation ;  is  to  search  over  the  economy  until  what- 
ever lesion  exists  is  exposed  and  comprehended. 

If  a  first  view  is  directed  to  the  nervous  system  itself,  we  look  for 
a  lesion  in  the  part  which,  by  the  expression  of  pain,  seems  most 
markedly  implicated.  The  most  decided  cases  of  neuralgia  are,  with- 
out doubt,  odontalgic, — a  tooth  decays  until  the  cavity  containing  the 


438  ORAL  DISEASES  AND  SURGERY. 

delicate  nerve  is  exposed  ;  the  neuralgia  has  the  simple,  single 
si"-nification  of  a  direct  irritation  ;  exostosis  of  a  tooth  root  presses 
on  nerves  ramifying  in  the  alveolo-dental  periosteum  :  the  significa- 
tion is  a  similar  one. 

Let  us  refer  to  a  neuralgia  occurring  in  the  stump  of  amputation. 
Is  the  cause  not  most  frequently  found  in  the  squeezing  and  pinch- 
in"-  of  a  nerve  caught  in  the  cicatrix?  Is  it  not  the  same  history 
where  tumors  grow  about  and  press  upon  some  nerve  periphery? 
But  I  had  meant  rather  just  here  to  call  attention  to  derangement 
in  nerve  substance  itself,  without  associated  or  influencing  lesion, 
if  we  might  be  able  to  find  such  derangements.  Might  I  instance 
neuromatous  expansion  as  found  in  stumps — and  which  are,  evidently 
enough,  sources  of  pain?  Are  there  idiopathic  inflammations  of 
nerve  substance  ?  or  do  nerves  in  themselves  degenerate  and  ulcer- 
ate ?  We  may  look  at  the  subject  from  a  still  wider  stand-point. 
There  is  no  earthly  doubt  that  a  pure  nervous  irritation  of  the  sys- 
tem at  large  may  exist.  There  is  certainly  an  individuality  exist- 
ing in  this  system.  It  has  a  mode  of  action  of  its  own,  and  this 
action,  as  remarked  by  Dr.  Wood,  is  susceptible  of  exaltation,  de- 
pression, or  deprivation  in  itself,  and  from  the  influences  of  its  own 
peculiar  agents.  But  can  or  do  these  vicissitudes  express  themselves 
ever,  or  even  occasionally,  in  sharp  neuralgic  pains  ?  Connected 
with  the  digestive  function  we  have  often  nausea  and  vomiting; 
with  the  secretory,  disorder  of  the  liver  and  kidneys;  with  the  respi- 
ratory, hurried  and  otherwise  irregular  breathing ;  w^ith  the  circu- 
latory, a  frequent  and  agitated,  though  seldom  full  or  energetic,  pulse. 
"As  the  offices  of  the  brain,"  says  Wood,  "are  various,  so  also  must 
be  the  signs  of  its  excessive  excitation.  Irritation  in  the  brain  obeys 
the  general  laws  of  that  morbid  affection.  If  moderate,  it  exalts  the 
healthy  functions  without  otherwise  altering  them ;  if  stronger,  it 
more  or  less  degenerates  the  functions  ;  in  great  excess,  it  entirely 
changes  or  abolishes  them.  Thus,  sensation  and  perception  may 
be  rendered  simply  more  acute  ;  or  may  be  deranged,  producing 
vertigo,  pain,  and  every  variety  of  disorder,  in  vision,  hearing, 
touch,  etc.,  from  buzzing  in  the  ears,  unnatural  coloring  of  objects, 
a  sense  of  tingling,  formication,  etc.,  to  complete  hallucination.  The 
intellectual  faculties  and  the  emotions  may  be  excited  into  inci'eased 
vigor,  or  may  be  completely  perverted,  as  in  delirium  and  insanity. 
The  general  overseeing  faculty  of  the  brain  may  be  simply  stimu- 
lated to  increased  vigilance,  to  a  more  ready  and  rapid  response  to 
all  the  intimations  of  its  dependent  functions  ;  or  it  may  be  thrown 


j  NEURALGIA.  439 

tinto  excessive  disorder,  evinced  by  restlessness,  jactitation,  obstinate 

"sleeplessness,  etc.     The  motor  faculty  may  merely  impart  increased 

activity  and  energy  to  the  muscles  under  the  influence  of  the  will ; 

or  it  may  throw  off  more  or  less  completely  subordination  to  that 

principle,  and  give  rise  to  every  variety  of  spasm  and  convulsion. 

Finally,  all  the  functions  above  referred  to  may  be  overwhelmed  by 

an  excess  of  irritation,  and  more  or  less  completely  lost  in  stupor 

I  and  coma.     This  is  nerve  irritation,  from  causes  or  influences  which 

preside  in,  or  in  association  with  the  system,  and  to  be  considered 

•alone  in  connection  with  the  sy.stem." 

Reactions  of  vascular  perversion  on  the  nervous  system  are  to 
I  be  considered.  Coup  de  soleil  and  apoplexy  may  be  esteemed  the 
I  opposite  conditions  in  such  reactions  How  frequently  have  all  the 
phenomena  of  partial  compi'ession — headache,  giddiness,  buzzing  in 
the  ears,  disordered  vision,  tingling,  formication,  numbness,  drowsi- 
ness, mental  confusion,  spasms,  convulsions,  etc. — been  quickly  re- 
solved and  removed  by  the  accidental  rupture  of  a  nasal  vein  having 
communication  with  a  meningeal  sinus  !  And  how  happily,  when 
similar  conditions  hav^e  come  on  from  long-continued  chlorosis,  has  a 
course  of  iron  relieved  them  !  Every  portion  of  the  encephalic  mass, 
every  portion  of  its  continuation  in  the  spinal  canal,  every  nerve 
periphery,  requires  a  certain  amount  of,  and  a  certain  character  of, 
blood,  to  keep  it  in  proper  poise  and  nutrition.  Too  much  blood,  and 
too  nutritious,  and  we  have  derangement  from  overstimulation ; 
too  little,  and  too  poor,  we  have  it  from  lack  of  pressure,  lack  of 
nutrition,  and  from,  in  many  cases,  effusions. 

Derangements  in  respiration  act  as  predisposing  causes  to  neu- 
ralgia. A  patient  who  labors  under  an  inability  to  aerate  his  blood, 
whatever  may  be  the  cause,  fails  to  relieve  that  fluid  of  certain 
poisonous  qualities,  which,  of  a  necessity,  sooner  or  later  must  dis- 
turb the  nervous  economy. 

Anything  and  everything,  in  short,  it  may  be  said,  which  acts  as 
a  depressant  in  the  vital  economy,  whether  by  overstimulation  or 
by  under-nutrition,  is  to  be  thought  of,  and  considered,  in  neural 
derangements ;  overstudy,  sensual  excess,  indigestion,  hepatic  and 
nephritic  diseases,  repression  of  the  cutaneous  circulation,  the  de- 
pressing passions,  as  fear,  grief,  melancholy  ;  the  employment  of 
sedative  poisons,  as  opium,  tobacco,  chloroform ;  living  in  an  atmos- 
phere impregnated  with  irrespirable  gases, — any  and  all  of  these 
may  assist  some  otherwise  incapable  lesion  in  determining  an  attack 
of  neuralsria. 


440  ORAL  DISEASES  ASD   SURGERY. 

The  most  extreme  case  of  nervous  mania  that  has  ever  come  under 
mv  own  observation,  accompanied  with  general  hyperaesthesia  and 
local  neuralo-ia,  was  in  the  person  of  a  carter,  addicted  to  habitual 
smokin"-.  For  three  days  this  man  was  uncontrollable  by  any  but 
physical  restraint ;  at  the  end  of  which  period,  having  secured  a 
short  interval  of  sleep  and  quiet,  I  placed  between  his  lips  a  pipe  of 
the  strongest  tobacco.  I  finally  cured  the  patient,  making  the  sec- 
tion of  a  nerve,  and  treating  him  with  tobacco  and  sedatives,  just  as 
one  treats  delirium  tremens  with  whisky  and  sedatives.  In  this  case 
I  am  entirely  satisfied  that  the  local  neuralgia  was  goaded  to  its 
intensit}'  by  the  perverted  condition  of  the  general  nervous  system. 
Several  cases  of  similar  import  I  can  recall,  associated  with  the 
improper  use  of  opium,  and  with  the  abuse  of  the  sexual  instincts. 

In  a  letter  to  the  London  Times,  republished  in  the  Medical 
Times  mid  Gazelle,  Sir  Benj.  Brodie  expresses  his  general  disap- 
probation of  the  habitual  use  of  tobacco,  and  makes  the  following 
observations  on  its  deleterious  effects: 

"  The  effects  of  this  habit  are  indeed  various,  the  difference  de- 
pending on  difference  of  constitution  and  difference  in  the  mode  of 
life  otherwise.  But,  from  the  best  observations  which  I  have  been 
able  to  make  on  the  subject,  I  am  led  to  believe  that  there  are  very 
few  who  do  not  suffer  harm  from  it,  to  a  greater  or  less  extent.  The 
earliest  symptoms  are  manifested  in  the  derangement  of  the  nervous 
system.  A  large  proportion  of  habitual  smokers  are  rendered  lazy 
and  listless,  indisposed  to  bodily,  and  incapable  of  much  mental,  ex- 
ertion. Others  suffer  from  depression  of  the  spirits,  amounting  to 
hypochondriasis,  which  smoking  relieves  for  a  time,  though  it  ag- 
gravates the  evil  afterward.  Occasionally  there  is  a  general  nervous 
excitability,  which,  though  very  much  less  in  degree,  partakes  of  the 
nature  of  the  delirium  tremens  of  drunkards.  I  have  known  many  in- 
dividuals to  suffer  from  severe  nervous  pains,  sometimes  in  one,  some- 
times in  another  part  of  the  body.  Almost  the  worst  case  of  neuralgia 
that  ever  came  under  my  observation,  was  that  of  a  gentleman  who 
consulted  the  late  Dr.  Bright  and  myself  The  pains  were  universal, 
and  never  absent;  but  during  the  night  they  were  especially  intense, 
so  as  almost  wholly  to  prevent  sleep.  Neither  the  patient  himself 
nor  his  medical  attendant  had  any  doubts  that  the  disease  was  to  be 
attributed  to  his  former  habit  of  smoking,  on  the  discontinuance  of 
which  he  slowly  and  gradually  recovered.  An  eminent  surgeon, 
who  has  a  great  experience  in  ophthalmic  diseases,  believes  that,  in 
some  instances,  he  has  been  able  to  trace  blindness  from  amaurosis 


NEURALGIA.  44I 

to  excess  in  tobacco  smoking  ;  the  connection  of  the  two  beino- 
pretty  well  established  in  one  case  by  the  fact  that,  on  the  practice 
being  left  off,  the  sight  of  the  patient  was  gradually  restored.  It 
would  be  easy  for  me  to  refer  to  other  symptoms  indicating  deficient 
power  of  the  nervous  system  to  which  smokers  are  liable  ;  Ijut  it  is 
unnecessary  for  me  to  do  so  ;  and,  indeed,  there  are  some  which  I 
would  rather  leave  them  to  imagine  for  themselves  than  undertake 
the  description  of  them  myself  in  writing. 

"  But  the  ill  effects  of  tobacco  are  not  confined  to  the  nervous 
system.  In  many  instances  there  is  a  loss  of  the  healthy  appetite 
for  food,  the  imperfect  state  of  the  digestion  being  soon  rendered 
manifest  by  the  loss  of  flesh  and  the  sallow  countenance.  It  is  dif- 
ficult to  say  what  other  diseases  may  not  follow  the  imperfect  as- 
similation of  food  continued  during  a  long  period  of  time.  So  many 
causes  are  in  operation  in  the  human  body  which  may  tend  in  a 
greater  or  less  degree  to  the  production  of  organic  changes  in  it,  that 
it  is  only  in  some  instances  we  can  venture  to  pronounce  as  to  the 
precise  manner  in  which  a  disease  that  proves  mortal  has  origin- 
ated. From  cases,  however,  which  have  fallen  under  my  own  ob- 
servation, and  from  a  consideration  of  all  the  circumstances,  I  cannot 
entertain  a  doubt  that,  if  we  could  obtain  accurate  statistics  on  the 
subject,  we  should  find  that  the  value  of  life  in  inveterate  smokers  is 
considerably  below  the  average.  Nor  is  this  opinion  in  any  degree 
contradicted  by  the  fact  that  there  are  individuals  who  in  spite  of 
the  inhalation  of  tobacco  smoke  live  to  be  old,  and  without  any  ma- 
terial derangement  of  the  health  ;  analogous  exceptions  to  the  gen- 
eral rule  being  met  with  in  the  case  of  those  who  have  indulged  too 
freely  in  the  use  of  spirituous  and  fermented  liquors." 

With  such  general  considerations  of  the  matter,  I  may  pass  to 
illustrations  in  the  recital  of  individual  cases.  By  the  study  of 
these  cases  the  student  will,  I  trust,  secure  proper  ideas  of  practice. 

Case  I. — Mrs.  B.,  the  wife  of  an  undertaker,  suffered  for  a  long 
period  from  periodic  attacks  of  pain  about  the  face  and  head.  This 
person,  exceedingly  quiet  and  retiring,  spent  most  of  her  life  in 
sunless  rooms,  surrounded  by  the  melancholy  paraphernalia  pertain- 
ing to  the  business  of  her  husband.  She  w^as  anaemic,  and  of  poor 
general  health  and  spirits.  Although  this  patient  had  certain  bad 
teeth,  yet  the  pain  had  never  seemed  associated  with  them  ;  indeed, 
so  insensible  were  these  organs  to  ordinary  agents  of  irritation,  that 
a  diagnosis  was  founded  alone  on  her  general  condition  and  sur- 
roundings, and  remedies  applied  entirely  in  such  direction.     Tonics 


442  ORAL  DISEASES  AND  SURGERY. 

were  administered,  window-shutters  were  unbowed,  exercise  and 
amusement,  conjoined  with  generous  living,  were  advised;  even 
with  this  entire  change  the  patient  failed  to  improve,  but,  on  the 
contrary,  grew  worse.  The  diagnosis  thus  discovered  to  be  at  fault, 
the  teeth  were  extracted;  still  the  condition  persisted,  and  the  pain 
increased.  She  was  now  treated  for  over  a  year,  the  pharmacopoeia 
bein"-  exhausted  in  her  case.  Called  in  consultation,  I  determined 
to  make  a  most  careful  exploration  of  her  whole  system.  At  this 
period  the  pain  had  assumed  and  continued  the  impression  of  an 
iron  clamp  over  the  head,  terminating  beneath,  and  which  clamp 
seemed  daily  contracting  itself  The  terror  and  pain  of  this  im- 
pression had  become  so  great  as  to  convert  the  patient  almost  into  a 
lunatic.  I  found,  by  inquiry,  that  her  internal  organs  had  been 
most  carefully  examined,  and  inferred  not  to  be  in  fault.  My  own 
investigations,  therefore,  were  commenced  externally.  First,  was 
there  any  remaining  tooth  or  teeth  implicated?  I  examined  for 
caries,  for  pulpitis,  for  nodules,  for  necrosis,  for  supernumerary  teeth, 
for  exposed  cementum  ;  but  fully  assured  myself  these  organs  were 
in  no  wise  involved.  I  examined  the  spinal  cord,  and  through  its 
expressions,  the  encephalic  mass ;  organically,  the  trouble  was  not 
reflex  from  these  points.  I  examined  every  articulation,  the  line 
of  every  artery,  vein,  and  nerve,  so  far  as  I  might  follow  them.  I 
passed  in  review  every  observation  and  fact  which  might  enlighten 
me,  but  without  success,  so  far  as  any  discovery  of  an  exciting  cause 
was  concerned.  Finally,  I  retui'ned  to  the  oral  cavity.  The  teeth 
which  had  been  extracted  the  year  before  were  the  molars  and  pre- 
molars of  the  left  superior  jaw.  Might  there  not  possibly  have  been 
just  the  smallest  particle  of  one  of  these  teeth  left  in  its  socket  ?  I 
was  making  pressure  in  the  canine  fossa,  when  the  patient  made 
slight  complaint ;  it  was  the  only  point  which  yielded  difference  in 
sensation.  Now,  what  was  this  sensation,  and  what  did  it  mean? 
It  was  not  pain  of  which  the  patient  complained,  not  discomfort ;  it 
was  simply  difference  of  sensation.  But  it  w^as  an  only  point  which 
bad  yielded  expression ;  it  was  therefore  differentially  just  to  infer 
that  here  existed  something, — the  lesion,  perhaps,  of  which  we  were 
in  search.  Acting  on  this  only  hint,  I  obtained  the  consent  of  the  phy- 
sicians in  attendance  to  make  an  exploratory  trephine  of  the  antrum, 
and,  on  performing  the  operation,  discovered  lying  within  the  cavity 
that  branches  of  the  intraorbital  nerve  running  across  it  had  enlarged 
to  the  size  of  ordinary  knitting-needles.  These  enlarged  nerves,  of 
which  there  were  two,  I  cut  away.     The  patient  was  immediately 


NEURALGIA.  443 

relieved,  and,  although  a  year  has  passed,  she  has  had  no  recurrence 
of  her  neuralgia. 

Case  II. — This  day,  October  16,  1868,  have  treated  and  dismissed 
a  patient,  a  young  lady,  who  shortened  a  summer  and  fall  campaign 
to  come  to  Philadelphia  for  advice  concerning  neuralgia  faciei,  and 
of  the  ear  and  scalp.  She  describes  her  agony  as  being  sometimes 
so  great  that  only  from  chloroform  could  she  get  even  a  temporary 
relief;  has  been  taking  tonics  and  opiates  throughout  the  summer ; 
has  had  no  pain  in  any  of  her  teeth,  although  on  the  upper  jaw  is  a 
pulpless  molar.  Examining  her  mouth,  my  attention  was  attracted 
to  a  peculiar  overriding  of  the  second  bicuspid  tooth  of  the  lower 
jaw  by  the  first  molar ;  the  employment  of  a  delicate  curved  probe 
revealed  caries  of  the  first  of  these  teeth,  exposing  the  pulp ;  the 
tooth  was  extracted,  the  distant  and  apparently  dissociated  neu- 
ralgia instantly  disappeared. 

A  tendency  to  nervous  irritability  which  exists  in  this  patient  may 
very  well  be  rearoused  by  the  presence  of  the  upper  dead  molar;  if 
this  should  prove  the  case,  she  is  advised  to  have  it  extracted. 

Case  III. — Neuralgia  of  Neck  and  Arm  from  Carious  Molar. — 
Dr.  Hyde  Salter,  well  known  in  connection  with  clinical  practice,  had 
sufi'ered  much  from  attacks  of  inflammation  in  the  left  lower  anterior 
molar,  which  was  extensively  excavated  by  caries.  At  the  age  of 
seventeen  these  acute  symptoms  had  ceased  for  two  or  three  years, 
leaving  nothing  but  a  grumbling  uneasiness  in  it.  At  this  time 
neuralgic  pains  began  to  extend  from  the  tooth  down  into  the  neck 
and  left  side,  and  thence  over  the  collar-bone  down  the  left  arm — 
these  pains  enduring  several  days  and  then  remitting.  There  was 
no  actual  pain  in  the  tooth  itself,  nor  any  tenderness  in  it,  nor  in  the 
adjacent  gum,  nor  any  appearance  of  inflammation.  The  situation 
of  the  pain  in  the  neck  and  clavicular  and  supramaxillary  regions 
was  exactly  that  of  the  descending  cutaneous  branches  of  the  cervi- 
cal plexus,  and  the  part  of  the  arm  where  the  aching  was  the  most 
intense  and  intolerable  was  at  the  insertion  of  the  deltoid.  These 
symptoms  disappeared  with  the  extraction  of  the  offending  tooth, 
and  have  never  since  returned. 

Case  IV. — Intense  Neuralgia  of  the  Eyeball  and  Face;  Altera- 
tion of  the  Color  of  the  Iris ;  Carious  Teeth— Mrs.  C,  aged  thirty, 
had  suffered  for  ten  years  from  severe  neuralgia,  affecting  the  left 
eyeball  and  left  side  of  the  head  and  face,  the  iris  of  the  affected  eye 
having  changed  from  a  deep  and  bright  hazel  to  a  dull  gray.  The  left 
lower  dens  sapientiifi  and  the  first  upper  bicuspid  being  found  badly 


444  ORAL   DISEASES  AND  SURGERY. 

carious,  these  were  extracted,  and  the  operation  was  attended  by  a 
terrible  paroxysm  of  neuralgia;  but  after  this  had  subsided  the 
patient  experienced  relief  for  about  three  months,  when,  the  old 
pain  returning,  the  second  upper  bicuspid  was  found  to  be  carious 
and  intensely  tender,  and  upon  its  removal  a  considerable  exostosis 
was  found  on  the  root.  The  pain  vanished  with  the  tooth.  {Guyh 
Hosjnfal  Reports.) 

Case  Y. — Neuralgia  of  Loicer  Jaio ;  Necrosis. — M.  C,  a  laborer, 
applied  for  treatment,  complaining  of  unbearable  pain  situated  about 
the  roots  of  the  inferior  central  incisor  teeth.  The  most  careful  ex- 
amination revealed  no  explanation,  and  the  patient  was  dismissed 
for  the  day  with  an  opiate  prescription.  A  second,  and  many  suc- 
ceeding examinations,  failed  to  yield  a  diagnosis,  opiates  being  con- 
tinued during  the  period.  At  the  end  of  some  three  weeks  an  in- 
flammation supervened,  resisted  all  treatment,  and  finally  terminated 
in  a  necrosis,  which  cast  off  the  two  teeth  with  their  alveoli ;  the 
exfoliation  completed,  the  neuralgia  disappeared. 

Case  VI. — Dr.  Benjamin  Rush  relates  a  case  of  neuralgia  in  the 
nates,  which,  resisting  other  means  of  treatment,  finally  yielded  to 
the  extraction  of  a  tooth. 

Case  YII. — 3Iegrim. — A  protege  of  the  Princess  of  Conde  was 
bled  in  the  arm  and  foot  twenty  times  for  megrim  of  five  years'  stand- 
ing. It  at  last  being  thought  advisable  to  open  the  jugular  vein,  the 
princess  applied  to  M.  Petot  to  perform  the  operation.  But  this 
surgeon,  not  seeing  the  necessity  for  so  frequent  depletion,  begged 
to  examine  the  mouth,  and  found  in  the  lower  jaw,  in  which  the 
patient  had  for  a  long  time  pain  and  numbness,  eighteen,  instead  of 
sixteen,  teeth,  resulting  in  a  very  crowded  denture.  By  extracting 
the  second  molar  on  either  side  he  gave  complete  and  permanent 
relief  in  twenty-four  hours. 

Case  Till. — Neuralgia  Faciei  and  Odontalgia  from  Menstrual 
Irregidarities. — A  lady  of  rank  (Rayer),  long  suffering  from  amen- 
orrhoea,  was  subject  to  frequent  epistaxis,  pain  in  the  side,  and  swell- 
ing of  the  abdomen  and  feet.  These  symptoms  were  overcome,  and 
for  a  year  she  enjoyed  good  health ;  but  last  summer,  in  consequence 
of  mental  distress,  a  severe  neuralgia  came  on,  which  was  cured  for 
a  time,  but  soon  returned  with  the  following  curious  symptoms: 
every  evening  the  pains  recurred,  preceded  by  the  discharge  from 
between  the  upper  canine  and  bicuspids  of  the  left  side  of  a  matter 
which  was  at  first  thick,  viscid,  and  bloody,  but  afterward  clear, 
and  so  profuse  as  to  fill  a  small  vessel.     The  pains  continued  the 


NEURALGIA.  445 

whole  night.  No  remedies  gave  any  relief  but  opiates,  which  sup- 
pressed both  the  pain  and  discharge  and  gave  sleep. 

Case  IX. — A  nun  (Wepser),  aged  forty,  was  seized,  at  one  of  her 
menstrual  periods,  with  pain  in  the  head,  eyes,  and  teeth.  A  tooth 
on  the  left  side  was  extracted,  but  without  relief;  the  pain  passed  to 
the  right  side,  and  for  five  weeks,  with  occasional  intervals  of  from 
half  a  day  to  two  days,  caused  much  suffering,  first  on  one  side  of 
the  head,  then  on  the  other,  the  principal  seat  of  the  pain  being  a 
space  two  or  three  fingers  broad  on  the  side  of  the  head.  When  the 
attacks  were  violent  they  were  preceded  by  a  strongly-marked  chill, 
the  throbbing  of  the  temporal  artery  was  very  perceptible,  the  eye 
injected,  and  when  the  paroxysms  were  at  their  height  flushings 
were  experienced.  In  the  treatment  of  this  case,  as  the  teeth  were 
discovered  to  be  not  at  all  in  fault,  the  surgeon  opened  an  issue  in 
each  arm  and  a  third  on  the  neck,  all  three  of  Avhich  were  made  to 
discharge  freely.  Attention  was  also  paid  to  the  nervous  system, 
with  a  view  to  give  it  tone  and  strength.  Not  much  regard  was 
paid  to  the  amenorrhoea,  because  at  such  age  the  menses  are  usually 
very  scant. 

In  both  the  above  cases  the  practitioners  failed  of  a  successful 
treatment,  and  evidently  for  the  reason  that,  in  both  cases,  treat- 
ment was  misdirected.  A  reflected  or  radiated  irritability  of  the 
uterus  was  without  doubt  the  lesion — an  ulcer  or  other  local  lesion 
being  the  offense. 

Affections  of  the  NervouH  System  dependent  on  Diseases  of  the 
Permanent  Teeth. — Mr.  Salter  contributes  to  Guy''s  Hospital  Re- 
po7^ts  a  most  interesting  paper  under  the  foregoing  title,  which  con- 
tains much  information  of  direct  and  practical  value,  and  with 
which  illustration,  and  some  suggestive  features  in  treatment,  the 
chapter  may  be  concluded.  "  Disorders  of  this  kind,"  says  Mr. 
Salter,  "  are  divided  into  those  which  are  reflex,  secondary,  and  re- 
mote ;  and  those  which  are  direct,  immediate,  and  from  contiguity. 
In  the  former  category  would  rank  epilepsy,  neuralgia,  paralysis  ;  in 
the  latter  local  pain,  facial  palsy,  some  forms  of  amaurosis,  etc.  In 
other  instances,  such  as  those  in  which  exalted  sensibility  of  the 
tegumentary  nerves  of  the  face,  or  erratic  pains  through  the  maxil- 
lary nerves  are  associated  with  toothache,  it  might  be  difficult  to  say 
whether  the  phenomena  are  mostly  reflex  or  direct ;  they  probably 
comprise  both  conditions.     .     .  The  posterior  lower  molars  are 

but  little  removed  from  the  tonsils  and  Eustachian  tube,  from  the 
parotid  region,  and  from  the  external  auditory  passage.     The  fangs 


446  ORAL  DISEASES  AND  SUEGERF. 

of  the  upper  back  teeth  are  close  to  the  orbit  and  its  all-important 
contents  ;  and  more  posteriorly  they  approach  the  spheno-maxillary 
fossa  and  fissure.  Thus  it  is  easy  to  account  for  the  nervous  com- 
plications which  are  directly  entailed  by  the  spread  of  inflammation 
from  the  periosteum  of  diseased  teeth. 

"  By  far  the  commonest  reflex  nervous  disturbances  to  which  den- 
tal irritation  gives  rise  are  neuralgic  pains  of  the  head  ;  and  this  is 
especially  the  case  where  the  upper  teeth  are  implicated.  In  the 
supra  and  infraorbital  nerves,  the  globe  of  the  eye,  the  temples,  and 
particularly  a  spot  near  the  vertex,  a  little  on  one  side  (the  side  of 
the  affected  tooth),  in  all  these  regions  '  dental  neuralgia'  is  really 
very  common ;  and  I  have  observed,  not  unfrequently,  that,  where 
the  pain  has  continued  long,  the  integument  has  become  hot,  and 
tender,  and  red.     .     .     . 

"  The  several  branches  of  the  trigeminus  appear  to  be  the  most 
susceptible  of  reflex  affection,  caused  by  the  dental  irritation  of  one 
of  them ;  but  next  to  the  different  elements  of  the  fifth  nerve,  the 
branches  of  the  cervical  and  brachial  plexuses  are  most  commonly 
involved.  Thus  pains  in  the  neck,  shoulder,  acromion  process,  in- 
sertion of  the  deltoid,  or  bend  of  the  elbow,  are  by  no  means  uncom- 
mon, and  with  them  occasionally  a  loss  of  motor  power,  a  weary 
sense  of  fatigue  in  the  flexor  muscles,  and  an  inability  to  grasp 
firmly  with  the  hand.  It  would  really  seem  that  there  is  occasion- 
ally, and  in  some  individuals,  a  special  and  exceptional  communica- 
tion between  the  fifth  nerve  and  those  of  the  arm.  Dr.  Anstie  has 
seen  two  instances  in  which  wounds  of  branches  of  the  ulnar  nerve 
have  caused  reflex  neuralgia  of  the  fifth  nerve.  And  he  remarks 
upon  this  circumstance  :  '  That  the  mental  perception  of  the  patient 
should,  in  each  of  these  cases,  refer  the  pain,  not  to  any  point  in 
the  course  of  the  injured  nerve,  but  to  the  branches  of  the  trigeminal, 
affords,  in  my  opinion,  a  strong  suggestion  that  that  portion  of  the 
central  nervous  system  with  which  the  trigeminus  is  directly  con- 
nected, presents  some  congenital  or  acquired  peculiarity  of  organi- 
zation.' This  idea  is  fully  borne  out  by  what  one  occasionallj^,  but 
only  occasionally  and  exceptionally,  sees  in  the  occurrence  of  bra- 
chial neuralgia  and  paralysis  caused  by  dental  irritation  of  the 
branches  of  the  fifth  nerve. 

"  Reflex  nervous  irritation,  dependent  upon  dental  disease,  is 
most  uncertain  and  capricious  in  its  manifestations.  One  person 
will  suffer  much  from  a  comparatively  slight  cause,  while  in  others 
the  same  condition  more  severely  developed  will  produce  no  such 


NEURALGIA. 


447 


result.  There  is,  unquestionably,  in  some  persons  a  neuralgic  diath- 
esis ;  and  it  is  not  improbable  also  that,  in  some  individuals,  there 
may  be  a  congenital  or  induced  peculiarity  in  the  centric,  or,  perhaps, 
collateral  relations  of  certain  nerves,  by  which  the  exalted  polarity 
of  one  may  be  passed  on,  and  so  reflected  upon  another  with  ab- 
normal facility.  In  persons  obnoxious  to  these  forms  of  neuralgia 
from  dental  irritation,  nothing  is  so  liable  to  produce  an  attack  as 
exhaustion  or  depressed  nutrition ;  and  patients  will  often  tell  you 
that  the  attacks  only  come  on  when  they  are  very  tired,  or  have 
gone  long  without  food. 

"Pain  is  only  one  of  the  phenomena  of  reflex  dental  nerve  irritar 
tion.  It  may  induce  muscular  sjmsm,  muscular  paralysis,  paral- 
ysis of  some  of  the  nerves  of  special  sense,  perverted  nutrition. 

"As  regards  the  teeth  themselves  which  excite  this  exalted  nerv- 
ous irritability,  nearly  all  their  diseases  appear  capable  of  causing 
this  condition.     Thus : 

"  Caries,  with  or  without  exposure  of  the  pulp  ;  exostosis  ;  hy- 
pertrophy of  the  crusta  petrosa ;  nodular  developments  of  dentine  in 
the  pulp  cavity ;  periostitis,  plastic  or  suppurative ;  impaction  of 
permanent  teeth  in  the  maxillary  bones ;  crowding  of  teeth  from  in- 
sufficient room. 

"  Each  and  all  of  the  above-enumerated  abnormities  of  teeth  have 
caused  manifestations  of  reflex  nervous  irritation,  though,  as  I  have 
remarked,  they  may  exist  in  the  severest  forms  without  producing 
any  such  result. 

"Mr.  Salter  then  records  a  series  of  cases  illustrative  of  the  vari- 
ous pathological  conditions  referred  to,  of  which  we  are  forced  to 
give  the  following  brief  abstract : 

KEFLEX    AFFECTIONS. 

''Facial  Neuralgia  from  Dentine  Excrescence  in  Pulp  Cavity. — 
A  woman  complained  of  severe  neuralgic  pains  obviously  connected 
with  an  upper  central  incisor.  The  pain  was  of  a  gnawing  character, 
abiding,  but  not  constantly  severe  ;  frequently  merely  a  conscious- 
ness of  the  presence  of  the  tooth,  but  at  other  times  sharp  and  dart- 
ing, flashing  up  the  side  of  the  face,  etc.,  through  all  the  branches 
of  the  superior  maxillary  division  of  the  fifth  nerve  of  that  side,  and 
considerably  augmented  by  sudden  pressure,  a  tap  upon  the  tooth, 
or  marked  change  of  temperature.  The  tooth  was  apparently  sound, 
though  somewhat  elongated  and  slightly  loose.     No  exostosis  was 


448  ORAL  DISEASES  AND   SURGERY. 

found  on  the  root  after  extraction,  but,  on  making  a  section  of  it 
(vertical,  from  side  to  side),  an  excrescence  of  dentine  was  dis- 
covered growing  from  the  side  of  the  pulp  cavity  and  occupying,  for 
a  short  space,  more  than  half  its  diameter.  The  removal  of  the 
tooth,  though  accompanied  with  a  violent  paroxysm  of  neuralgic 
agony,  was  followed  by  a  total  cessation  of  the  pain,  which  never 
recurred. 

"Cranial  Nexiralgia  from  an  Impacted   Canine    Tooth.  —  Miss 

B had  '  cut '  all  the  permanent  teeth  in  due  course  and  position, 

except  the  left  upper  canine,  the  proper  space  for  which  was  oblit- 
erated by  the  contact  of  the  lateral  incisor  and  first  bicuspid.  At 
the  time  when  the  right  upper  canine  appeared,  a  hard  swelling  was 
noticed  in  the  palate,  on  the  left  side,  and  toward  the  front  of  the 
mouth,  and  this  slowly  developed  into  a  prominent  rounded  ridge, 
extending  obliquely  behind  the  left  incisors,  and  left  first  bicuspid. 
No  inconvenience  was  felt  up  to  the  age  of  eighteen,  when  severe 
headache,  confined  to  a  spot  on  the  vertex  toward  the  left  side,  at- 
tended by  local  heat,  etc.,  temporarily  relieved  by  pressure,  made 
its  appearance.  This  headache,  which  was  recurrent  in  its  nature, 
lasted  until  the  patient  was  twenty-six,  no  actual  pain  being  felt  in 
the  impacted  tooth,  although  the  region  about  it  became  hot  and 
tender  upon  the  supervention  of  the  headache.  The  removal  of  the 
tooth  by  Mr.  Cartwright — an  operation  involving  much  chipping 
away  of  the  bony  cavity  in  which  it  was  imbedded — was  followed 
by  immediate  and  permanent  relief,  thirty  years  having  elapsed 
with  no  return  of  the  symptoms. 

"Intense  and  General  Neuralgia  from  Exostosis  on  Fangs  of 
Teeth. — Miss  B.  P had  gone  through  her  first  dentition  with- 
out trouble,  but  on  account  of  some  crowding  on  the  advent  of  the 
permanent  teeth,  an  upper  and  lower  bicuspid  on  either  side  were 
extracted  to  make  room.  During  adolescence  she  was  attacked  by 
neuralgic  pains,  at  first  confined  to  branches  of  the  trigeminus,  but 
afterward  extending  to  the  arms,  legs,  etc.,  indeed,  nearly  the  whole 
body.  The  teeth,  though  apparently  sound,  had  a  tendency  to 
elongate  and  spread,  especially  the  upper  incisors,  with  which  the 
pain  was  at  first  chiefly  associated.  The  offending  teeth  always 
gave  pain  on  being  slightly  struck.  Mr.  Bell  removed,  from  time 
to  time,  the  teeth  most  obviously  connected  with  the  neuralgia,  in 
each  instance  with  temporary  relief  of  the  suffering,  and  in  every 
case  the  fangs  of  the  extracted  teeth  were  found  incrusted  with 
nodular  exostosis,  though  the  teeth  themselves  were  free  from  caries. 


NEURALGIA.  449 

When  Mr.  Salter  saw  Miss  P.  (in  1851)  only  the  two  lower  left 
bicuspids  remained,  and  these  were  causing  a  continuance  of  the 
neuralgia,  which  ceased  after  their  removal.  On  the  fangs  of  both 
these  teeth  were  the  expected  nodules  of  exostosis.  This  patient  is 
stated  to  have  been  remarkably  anaemic,  the  gums  being  '  like  wax 
stained  of  the  palest  pink,'  and  the  alveoli  remaining  white  and 
bloodless  for  some  seconds  after  extraction  before  blood  enough 
oozed  from  the  broken  vessels  to  partially  fill  the  hollow  sockets. 

'' Neuralgia  of  the  Arm  from  Carious   Teeth  and  from  undue 

Pressure  of  Artificial  Teeth. — In  the  case  of  Mrs.  E ,  caries  of 

any  of  the  lower  teeth  on  the  left  side  has  been  immediately  followed 
by  severe  neuralgic  pain  at  a  spot,  small  and  circumscribed,  on  the 
front  of  the  left  forearm,  about  two  inches  below  the  line  of  flexion. 
Having  now  lost  all  her  teeth,  and  wearing  a  complete  artificial  set, 
whenever  the  lower  denture  hurts  the  jaw  on  that  side,  the  same 
symptom  is  manifested.  The  right  side  has  never  been  similarly 
affected. 

"Chronic  Trismus  from  Impaction  of  Lower  Dens  Sapientise. — 
In  a  man  aged  twenty-three,  with  large  teeth  and  comparatively 
small  maxillary  bones,  the  lower  wisdom  teeth  were  imbedded,  and 
unable,  from  want  of  room,  to  come  into  place.  The  result  was  re- 
current pain  and  swelling  within  the  mouth,  followed  by  a  sudden 
attack  of  'lock-jaw,'  apparently  caused  by  contraction  of  the  left 
masseter  muscle,  which,  after  four  months'  duration,  was  cured  by 
extraction  of  the  left  second  molar,  the  wisdom  tooth  being  out  of 
reach.  The  posterior  fang  of  the  extracted  tooth  was  much  eroded 
by  absorption. 

"  Wry-neck  from  Carious  Teeth  of  Lower  Jaw. — A  young  woman 
whose  head  had,  for  more  than  six  months,  been  drawn  down  nearly 
to  the  left  shoulder,  with  considerable  pain,  was  relieved  in  a  few 
days  by  the  removal  of  a  stump  and  a  partially  decayed  tooth  from 
the  left  side  of  the  lower  jaw. 

"  Epilepsy  from  Carious  Tooth. — A  boy,  aged  thirteen,  under  the 
care  of  Dr.  Ramskill,  had  frequent  attacks  of  epilepsy,  occurring 
about  seven  or  eight  o'clock  in  the  evening.  Examination  detected 
'  a  molar  tooth  considerably  decayed,  with  a  swollen  gum  around 
it,  and  partly  growing  over  into  the  cavity.'  It  was  not  very  tender 
to  the  touch,  nor  did  the  examination  give  rise  to  toothache.  The 
extraction  of  this  tooth  was  followed  by  cessation  of  the  fits. 

"  Tetanus  from  3Iechanical  Irritation  of  the  Pulp. — The  case  of 
a  gentleman  (quoted  from  Tomes''s  Dental  Surgery),  who,   having 

29 


450  ORAL  DISEASES  AND  SURGERY. 

broken  off  a  front  tooth,  went  immediately  to  a  prominent  dentist  in 
Paris  and  had  an  artificial  crown  pivoted  with  a  gold  peg  upon  the 
fan".  After  severe  pain  for  four  or  five  days,  trismus  set  in  and  was 
soon  followed  by  tetanus  and  death. 

'' Neuralgia  of  Face,  Neck,  and  Arm,  with  Partial  Paralysis  of 
the  latter,  from  Carious  Wisdom  Tooth. — Miss  W ,  '  was  suf- 
fering from  constant  aching  pain  in  the  left  side  of  the  face  and  neck, 
and  in  the  left  arm.  The  pain  sometimes  became  intensely  severe. 
The  arm  had  lost  nearly  all  muscular  power.'  These  symptoms, 
after  resisting  all  medical  treatment  for  two  years,  disappeared  in  a 
few  hours  after  the  removal  of  the  tooth. 

"Amaurosis  causedhy  Crowding  of  Teeth. — In  this  case  (reported 
by  Mr.  Hancock  in  the  Lancet  of  1859,  p.  80),  a  boy,  aged  eleven, 
whose  sight  had  been  previously  unimpaired,  found  upon  waking 
one  morning  that  he  was  entirely  blind.  About  a  month  afterward 
he  was  admitted  to  Charing  Cross  Hospital,  where  it  was  discov- 
ered that  his  teeth  were  'much  crowded  and  wedged  together;  the 
jaws,  in  fact,  not  being  large  enough  for  them.'  Accordingly  two 
permanent  and  four  milk  molar  teeth  were  extracted,  and  '  on  the 
same  evening  the  boy  could  distinguish  light  from  darkness,  and  on 
the  following  morning  could  make  out  objects.  From  this  time  his 
sight  rapidly  improved,  and  he  was  dismissed  cured  on  the  28th 
(eleven  days  after),  the  only  treatment  beyond  the  removal  of  the 
teeth  being  two  doses  of  aperient  medicine.' 

"'Dr.  Watson  (Lectures  on  Physic,  fourth  ed.,  vol.  ii.  p  351) 
mentions  a  very  similar  case.  But  the  blindness  was  confined  to 
one  eye  ;  it  recurred  two  or  three  times,  and  was  on  each  occasion 
cured  by  tooth-extraction.' 

"Deafness  from  Carious  Teeth. — Mr.  Cattlin  reports  the  case  of 
a  lady  who  had  for  about  three  months  suflTered  acute  pains  in  a  dis- 
eased right  lower  molar,  and  in  the  corresponding  ear  and  side  of 
the  neck,  and  who  had  been  deaf  for  four  days.  '  The  inflamed  tooth 
was  extracted,  and  hearing  returned  within  an  hour  after  the  operar 
tion.' 

"Perverted  Nutrition  from  Dental  Nervous  Irritation. — Under 
this  heading  three  cases  are  quoted  from  Mr.  Hilton's  work  ('  On 
the  Influence  of  Mechanical  and  Physiological  Rest,  etc.'),  in  which 
the  tongue  was  decidedly  furred  only  on  the  side  corresponding  with 
carious  or  painful  teeth ;  one  in  which  the  hair  of  the  left  temple 
was  bleached  by  unilateral  neuralgia,  arising  from  a  carious  molar 
tooth ;  and  one  in  which  ulceration  of  the  auditory  canal,  accom- 


NEUBALGIA.  45I 

paniecl  with  offensive  discharges  from  the  ear,  and  enlargement  of 
one  of  the  cervical  glands,  vs^as  traced  to  a  diseased  lower  molar  on 
the  same  side,  and  subsided  soon  after  the  extraction  of  the  tooth." 
From  the  illustrations  given,  it  will  be  inferred  that  the  removal  of 
any  discovered  lesion  of  irritation  is  the  primary  indication  in  every 
case  of  neuralgia.  The  idea  has  been  advanced  that  there  is  seldom  or 
never  a  neuralgia  proper,  but  that  such  pain  is  simply  an  expression. 
It  is  unfortunately  the  case,  however,  that  too  often  we  are  compelled 
to  discover  our  weakness  in  a  search  after  causes,  and  are  thus  rendered 
unable  to  treat  a  case  scientifically,  but  are  driven  to  empiricism. 
Even  yet,  however,  we  may  render  more  than  an  accidental  service; 
and  the  principle  on  which  we  would  found  such  treatment  is  that 
of  soothing  and  quieting,  either  as  applications  would  refer  to  the 
system  at  large,  or  to  the  particular  part  involved.  Nervines,  where 
there  is  general  nervous  disturbance,  independent,  as  far  as  we  dis- 
cover, of  other  derangements,  will  be  found  to  sometimes  act  very 
happily.  The  tinctures  of  valerian  and  gentian,  in  equal  proportion, 
given  in  tablespoonful  doses,  make  a  fine  combination.  Bromide  of 
potassium,  where  it  seems  necessary  to  keep  up  a  continuous  impres- 
sion, is  given  with  advantage  in  doses  of  ten  grains,  dissolved  in  a 
wineglass  of  water,  from  two  to  ten  times  a  day.  If  given,  however, 
in  a  paroxysm,  forty  to  sixty  grains  will  be  found  not  too  much,  and 
it  sometimes  will  be  well  to  combine  with  it  small  doses  of  opium 
or  morphia. 

R. — Potass,  brom.  grs.  xx; 

Morph.  acet.  grs.  ^  to  ^,  according  to  severity  of  pain  ; 
Aqua,  ^i.  M. 
To  be  repeated  pro  re  nata. 

Yalerianate  of  zinc  is  a  favorite  preparation  with  many  practition- 
ers. It  may  be  made  into  pills  with  conserve  of  rose,  or  any  pre- 
ferred vehicle,  each  pill  to  contain  from  one-half  to  a  full  grain,  to 
be  given  twice  or  thrice  a  day. 

Tincture  of  Indian  hemp  is  prescribed  in  doses  of  five  drops,  re- 
peated three  times  a  day. 

Where  there  is  disturbance  of  the  visceral  health,  it  has  been 
found  occasionally  successful  to  produce  rapid  but  moderate  saliva- 
tion. 

Aconite  made  into  quarter-grain  pills,  and  administered  cautiously, 
three  or  four  times  a  day,  is  recommended. 

Digitalis  in  tincture,  or  the  tincture  of  veratrum  viride,  in  condi- 


452  ORAL  DISEASES  AND  SURGERY. 

tions  of  undue  circulatory  excitement,  exhibited  in  five-drop  doses 
until  such  excitement  is  subdued,  will  sometimes  quickly  relieve  the 

pain. 

Colchicum,  where  there  is  a  supposed  gouty  association,  may 
always  be  employed.     The  wine  of  the  root  is  the  best  preparation. 

In  rheumatic  neuralgia,  or  pain  associated  with  a  rheumatic  con- 
dition, the  following  formula  will  be  found  very  reliable ;  certainly 
so,  if  some  other  existing  lesion  is  not  too  antagonistic : 

B. — Potass,  iod.  Iss; 

Ext.  belladonna,  gr.  vi ; 
Yin.  colch.  rad.  ^ss  ; 
Tinct.  guaiac.  ammoniat.  ^vi ; 
Aqua  cinnamomi,  ^vi.     M. 
Sig.  A  tablespoonful  to  be  taken  in  a  wineglass  of  water  three 
times  a  day  ;  if  it  should  purge,  five  drops  of  laudanum  may  be 
added  to  each  dose. 

Arsenic  is  frequently  used  with  decided  benefiL  It  may  be  ex- 
hibited in  granules  of  the  twentieth  of  a  grain  three  times  a  day.  It 
acts  well  in  cutaneous  neuralgia. 

Donovan's  solution — the  liq.  hydrarg.  arsen.  et  iod. — is  a  favor- 
ite with  many  practitioners.  Dose,  five  drops  three  times  a  day, 
avoiding  salivation.  It  is  an  alterative,  having  a  variety  of  signifi- 
cations. 

Iron  and  bark  should  be  employed  in  all  cases  associated  with 
lassitude  and  anaemia. 


R. — Elx.  ferri  cinch. 
Sig.  Teaspoonful  four  times  a  day. 

R. — Tinct.  ferri  chl.  §i ; 
Quinia  sulph.  5i-     M. 
Sig.  15  to  20  drops  three  to  four  times  a  day. 

R. — Syrupus  ferri  pyrophos,  ^vi ; 
Quinia  sulph.  5i-     M. 
Sig.  Teaspoonful  four  times  daily. 

Opium  and  ether,  given  in  full  doses  before  a  paroxysm,  with  ten 
or  fifteen  grains  of  quinine  administered  after  the  pain  has  ceased, 
will,  it  is  asserted,  at  once  make  an  impression,  and  frequently 


Or, 


Or, 


NEUBALGIA.  453 

abridge  the  next  paroxysm.  Success  is  claimed  for  the  exhibition 
of  opium  to  the  production  of  narcotism. 

Muriate  of  ammonia,  in  doses  of  half  a  drachm  three  or  four  times 
a  day,  has  been  given  with  advantage.  A  very  soothing  effect  is 
produced  by  placing  a  lump  of  the  ammonia  on  a  burning  coal  and 
thus  impregnating  the  atmosphere  of  a  room. 

Oil  of  turpentine  is  frequently  applauded  by  English  practitioners. 
It  may  be  given  in  doses  of  from  one-half  to  a  full  drachm. 

Chloroform,  or  chloroform  combined  with  camphor,  is  recom- 
mended.    A  formula  used  by  Dr.  Wood  is  as  follows : 

R. — Chloroform,  f5ij; 
Camphor,  5i- 
Mix  with  the  yolk  of  an  eg^  and  §vi  of  water,  and  direct  a  table- 
spoonful  to  be  taken  every  half  hour,  every  hour,  or  every  two 
hours,  according  to  the  urgency  of  the  case,  until  relief  is  obtained, 
or  some  decided  effects  are  experienced  from  the  medicines,  either 
on  the  stomach  or  brain. 

Vermifuge  medicines  are  frequently  prescribed  with  benefit,  par- 
ticularly in  the  case  of  children ;  parasites  frequently  keeping  up  an 
irritation,  although  presenting  no  definite  signs,  •f  these  medicines, 
one  of  the  very  best  is  the  combination  of  spigelia  and  senna. 

R. — Syrupus  spigelia  et  sennae,  ^iv. 
Sig.  Take  in  teaspoonful  doses  three  times  a  day.     Four  ounces 
will  be  enough  to  destroy  any  worms  which  may  be  present  in  the 
intestines. 

Cathartics  are  generally  indicated  in  spasmodic  attacks  of  neu- 
ralgia ;  especially  is  this  the  case  when  there  is  costiveness,  furre 
tongue,  sick  headache  or  stomach,  giddiness,  etc.  It  is  generally 
satisfactory  practice  to  precede  the  purgation  with  a  few  quarter- 
grain  doses  of  calomel.  The  character  of  the  purgative  is  to  be  in- 
fluenced by  the  condition  of  the  patient.  Sulphate  of  magnesia  is, 
I  think,  generally  found  applicable.  Blue  mass,  colocynth,  and 
jalap,  or  the  compound  cathartic  pill,  I  have  always  found  objec- 
tionable. Where  febrile  disturbance  is  present,  particularly  do  I 
think  these  combinations  will  be  found  to  do  much  more  harm  than 
good.  The  ordinary  Seidlitz  powder,  repeated  three  or  four  times 
within  the  day,  is  a  very  happy  and  really  refreshing  medicine.  If 
it  should  not  do  good,  it  will  certainly  do  no  harm. 


454  ORAL  DISEASES  AND  SURG  ERF. 

Strychnine  is  an  antineuralgic  medicine  of  much  reputation.  It 
may  be  prescribed  in  quantities  of  two  grains,  divided  into  eighty 
pills.     One  to  be  taken  three  times  a  day. 

Of  local  remedies  there  are  the  greatest  variety.     A  formula  long 

celebrated   under  the  name  of  Rauque's  liniment,  is  prepared  as 

follows : 

R. — Ext.  belladonna,  9ij ; 

Ether  sulph.  §i ; 
Laurel-water,  ^ij-     M. 
Sig.  Let  it  be  rubbed  on  the  part  and  saturated  flannel  be  ap- 
plied. 

The  endermic  application  of  morphia  is  a  common  practice.  The 
morphia  may  be  used  on  a  blistered  surface,  or  subcutancously  in- 
jected,— syringes  for  the  latter  purpose  being  made  by  all  instru- 
ment-makers. To  make  a  subcutaneous  injection,  it  is  only  neces- 
sary to  thrust  the  needle-point  of  the  syringe  into  the  rete  mucosum, 
or  it  may  be  passed  completely  beneath  the  skin  into  the  underlying 
cellular  structure. 

Hot  and  moist  applications  are  generally  found  of  much  service 
in  quieting  pain — the  part  to  be  enveloped  in  old  and  loose  flannel, 
and  evaporation  prevented  by  an  investment  with  oiled  silk  or  other 
material. 

In  afl"ections  of  the  fifth  pair,  Dr.  Richab,  of  Strasburg,  attributes 
great  good  to  one  grain  of  quinine  and  two  of  common  snufi",  intro- 
duced into  the  nostril  of  the  painful  side.  It  is  said  in  many  cases 
to  act  like  a  charm. 

Professor  Charles  Meigs  introduced,  several  years  back,  a  plan 
of  treatment  with  sulphuric  ether,  which  has  yielded  greater  tem- 
porary success  than  anything  else  I  have  ever  tried.  He  confused 
the  nerve  currents  by  taking  a  piece  of  sponge  saturated  with  ether, 
and,  by  a  continuous  but  irregular  round,  would  touch,  here  and 
there,  difi"erent  neighboring  surfaces,  until  the  pain  would  dis- 
appear. If,  for  example,  the  pain  was  in  the  forehead,  he  would 
touch  over  the  supraorbital  nerve,  over  the  infraorbital,  over  the 
anterior  dental,  over  the  facial,  over  the  cervical, — alternating  the 
touches  to  these  parts  for  a  period  varying  from  five  minutes  to  half 
an  hour.     In  most  cases  the  pain  will,  for  the  time,  be  relieved. 

Creasote,  much  diluted  in  simple  cerate,  is  sometimes  found  very 
useful  as  a  local  obtunder, — five  drops  of  creasote  to  the  ounce  of 
cerate  or  lard  to  be  rubbed  over  the  affected  part,  little  by  little,  until 
relief  is  obtained. 


NEURALGIA.  455 

Dr.  Kirby  directs  a  liniment  made  of  one  drachm  of  tincture  of 
aconite  to  seven  of  fresh  palm  oil,  or  with  two  ounces  of  camphor 
liniment.  A  half  drachm  of  the  former,  or  double  the  quantity  of 
the  latter,  to  be  rubbed  in  twice  or  thrice  a  day,  according  to  its 
effects.  It  must  be  watched,  however,  as  the  medicine  is  cumula- 
tive ;  if  its  poisonous  effects  appear,  stimulants  are  to  be  given. 

Dr.  Grave's  neuralgic  plaster  is  compounded  as  follows : 

R. — Powder  of  opium,  9ij  ; 
Camphor,  5ss ; 

Burgundy  pitch,  q.  s.  for  plaster  mass.  M. 
Stupe  the  parts  with  warm  water  before  applying  it. 

Cazenave's  pomade  is  thus  made : 

B. — Chloroform,  5i^; 

Cyanide  of  potassium,  5ijss ; 
Axunge,  giij ; 
Wax,  q.  s.  for  consistence. 
Rub  into  the  part  a  piece  of  the  ointment  the  size  of  a  pigeon's 
egg,  and  cover  with  oilskin. 

*^  Neuralgia:  Cases  treated  successfully  by  the  Spine-bag.  By  John 
Chapman,  M.D.,  M.R.C.P.,  M.S.C.S.,  Physician  to  the  Farringdon 
Dispensary. — The  cure  of  neuralgia,  whether  the  disease  be  treated 
by  drugs  given  internally,  or  by  applications  of  various  kinds  at  the 
seat  of  pain,  or  by  the  two  methods  conjointly,  is  confessedly  almost 
always  difficult,  and  in  a  large  proportion  of  cases  impossible.  The 
cases  reported  below  have  been  treated  by  a  method  altogether  new. 
By  stating  each  case  with  extreme  brevity,  I  am  enabled  to  present 
at  one  view  within  a  small  compass  the  results  of  several  experi- 
ments ;  and  I  do  this  in  the  hope  that  they  may  produce  such  an 
impression  on  the  minds  of  professional  readers  as  may  impel  them 
to  acquaint  themselves  with  the  pathological  and  therapeutical  prin- 
ciples of  which  these  results  are  an  expression.  I  shall  hereafter 
publish  an  exposition  of  these  principles,  illustrated  by  reports  of 
cases  in  extenso,  and  shall  then  give  a  full  description  of  the  treat- 
ment adopted. 

"  1.  Facial  Neuralgia. — T.  H.,  a  gentleman,  aged  35,  who  had 
been  suffering  during  the  previous  fortnight,  requested  my  advice 
March  18th,  1865.  He  was  in  great  pain,  which  had  been  con- 
tinuous from  the  previous  day,  and  which  had  wholly  deprived 
him  of  sleep.     The  pain  was  chiefly  on  the  right  side  of  the  face 


456  ORAL  DISEASES  AND  SURGERY. 

and  head  ;  but  during  the  morning  preceding  my  visit  the  left  side 
had  become  invaded.  The  affected  parts  were  very  tender,  and 
somewhat  swollen.  The  head  was  rather  hot,  the  face  flushed,  the 
tongue  thinly  coated  with  whitish  fur;  pulse  92,  full  and  strong. 
Several  medicines  prescribed  by  two  physicians  in  succession  had 
proved  of  no  avail. 

"I  applied  a  ten-inch  spinal  water-bag,  containing  water  at  130° 
F.,  to  the  cervico-dorsal  region,  and  shortly  afterward  left  the  pa- 
tient's room.  Within  half  an  hour  I  returned,  when  I  found  him 
asleep.  The  treatment  was  continued  for  two  days  by  means  of 
heat;  afterward  I  used  ice  (at  first  in  the  lumbar  region),  and  from 
the  time  he  first  fell  asleep  he  continued  free  of  pain,  which  has  not 
since  returned 

"  2.  Facial  Neuralgia. — Fraulein  S.,  aged  about  25,  consulted  me 
February  3d,  1867,  on  account  of  neuralgia  affecting  the  infraorbital 
and  dental  branches  of  the  trifacial  nerve.  The  pain  was  not  con- 
fined to  one  side  of  the  face,  but  was  sometimes  most  acute  on  one 
side,  sometimes  on  the  other ;  it  increased  at  night,  and  kept  her 
awake  the  greater  part  of  each  night.  She  had  been  suffering  in 
this  way  for  about  three  weeks  before  I  saw  her.  Her  general  health 
was  good.     The  affected  parts  presented  no  trace  of  hyperaemia. 

"  She  was  treated  by  means  of  ice,  and  experienced  almost  imme- 
diate relief  After  three  days  of  treatment  she  felt  and  slept  very 
much  better ;  and  before  the  end  of  the  fifth  day  the  pain  had  wholly 
ceased.  Nearly  a  year  afterward  she  told  me  that  it  had  never 
returned. 

"  3.  Facial  Neuralgia. — Mademoiselle  M.,  aged  20,  consulted  me 
in  August,  1867,  when  she  was  suffering  from  acute  facial  neuralgia, 
the  chief  foci  of  which  were  the  infraorbital  foramen,  and  the  men- 
tal foramen  of  the  right  side.  The  extreme  pain  came  on  in  fits, 
sometimes  at  8  a.m.,  sometimes  at  2  p.m.,  but  between  the  paroxysms 
the  face  continued  to  ache,  and  at  times  the  patient  had  pain  at  the 
back  of  the  head.  She  had  suffered  in  this  way  about  a  fortnight 
before  coming  to  me,  and  had  several  similar  attacks  during  the  pre- 
ceding year. 

"The  treatment  consisted  in  the  application  of  the  double-col- 
umned hot  water-bag.  The  malady  was  immediately  subdued  :  no 
distinct  paroxysm  occurred  after  the  first  application  of  heat;  all 
pain  rapidly  and  completely  subsided,  and  since  that  date  has  not 
returned. 

"4.  Dental  Neuralgia.— X.  W.  B.,  a  Russian  gentleman,  suffer- 


NEURALGIA.  457 

iug  from  dental  neuralgia,  consulted  me  in  September,  1867.  The 
malady  was  chiefly  confined  to  the  teeth  of  both  upper  and  lower 
jaw,  but  no  particular  tooth  or  teeth  seemed  to  be  especially  affected. 
The  pain  was  intermittent,  and  so  severe  as  to  interfere  seriously 
with  the  patient's  daily  occupation.  No  cause  of  the  disorder,  which 
had  continued  some  weeks,  could  be  discovered,  and  the  face,  so 
far  from  showing  any  sign  of  hypersemia  over  the  seat  of  pain, 
seemed  cooler  than  normal.  In  the  course  of  the  first  day  of  treat- 
ment by  means  of  the  spinal  ice-bag,  the  pain  was  completely  sub- 
dued ;  the  cold  was  persisted  in  for  some  time,  and  during  the  re- 
mainder of  the  patient's  stay  in  England  he  continued  free  from 
suffering. 

"5.  Dental  Neuralgia. — H.  E.,  female,  aged  21,  suffering  from 
violent  and  continuous  pain,  spreading  over  the  teeth  and  gums  of 
both  the  upper  and  lower  jaw,  consulted  me,  January  11th,  1868. 
The  pain  was  most  intense  in  the  lower  jaw  and  on  the  left  side ; 
she  had  intense  headache  also.  The  forehead  and  cheeks  were 
notably  hotter  than  normal,  and  she  complained  of  great  heat  in  the 
roof  of  the  mouth  as  well  as  in  the  gums — which  were  swollen  and 
sore.  During  the  previous  week  she  had  had  several  teeth  stopped 
with  gold :  one  of  them  became  most  especially  painful,  and  there 
was  threatening  of  an  abscess  at  its  root. 

"  The  treatment  consisted  in  the  application  of  cold  across  the 
occiput,  and  of  heat  over  the  cilio-spinal  regioh — in  the  first  instance 
separately,  and  afterward  simultaneously.  The  pain  was  speedily 
and  completely  annulled;  it  recurred,  and  was  again  annulled  by  the 
same  method  on  several  occasions.  The  patient  volunteered  the 
statement  that,  during  the  application  of  the  heat,  her  mouth  be- 
came perceptibly  cooler. 

"6.  Facial  and  Brachial  Neuralgia. — Mary  A.  T.,  aged  44,  first 
consulted  me  at  the  Farringdon  Dispensary,  December  28th,  1867, 
when  she  was  suffering  from  neuralgia  of  the  right  side  of  the  head, 
face,  and  neck,  and  along  the  right  shoulder  and  arm,  extending  to 
the  fingers.  The  right  half  of  the  tongue  was  also  affected.  The 
pain,  which  was  exactly  limited  to  the  median  line,  was  described 
by  the  patient — '  like  as  if  something  is  pulling  the  flesh  off  the 
bone,  it's  so  dreadful,  and  sometimes  as  if  the  parts  were  screwed 
up  in  a  vice.' 

"  She  was  treated  by  means  of  ice  applied  along  the  whole  spine. 
She  improved  immediately  and  rapidly,  and  as  early  as  January 
15th,  informed  me  that  she  had  not  had  'a  bit  of  neuraliga'  during 


458  ORAL  DISEASES  AXD   SURGERY. 

the  whole  of  the  preceding  week.  Up  to  this  date  (February  29th) 
the  pains  have  not  returned." 

Facial  Neuralgia  from  Exposed  Tooth  Pulp. — Mrs.  H.  had  suf- 
fered for  several  years  with  frequent  intense  and  persistent  facial 
neuralgia ;  had  been  under  the  care  of  four  physicians  ;  taken  most 
of  the  sedative,  antispasmodic,  tonic,  and  alterative  remedies  which 
could  be  named  ;  had  been  forbidden  to  go  out  of  the  house  after 
sundown  ;  was  not  allowed  to  put  her  hands  in  cold  water,  etc. 

When  consulted  in  reference  to  her  condition,  I  requested  that  a 
thorough  examination  of  her  teeth  should  be  made  by  a  competent 
dentist,  with  a  view  of  ascertaining  if  the  trouble  did  not  originate 
there.  This  was  acceded  to,  but  reluctantly,  because  no  pain  had 
been  felt  in  the  teeth.  It  was,  therefore,  with  some  show  of  gratifica- 
tion that  I  was  assured  subsequently  that  the  teeth  were  all  sound. 
I  begged,  as  a  special  favor,  another  and  more  thorough  examination, 
which,  very  much  to  my  gratification,  discovered  an  exposed  pulp. 
This  having  been  treated,  the  neuralgia  disappeared,  and  has  not 
since  returned,  a  period  of  two  years  having  elapsed.  (White.) 

Surgical  Interference  by  Operation. — Interference  by  direct 
operation  has  not,  as  a  general  thing,  been  as  satisfactory  as  could 
be  desired. 

Operative  surgery  in  neuralgia  refers  to  the  division  or  resection 
of  nerves.  In  facial  neuralgia,  where  such  interference  is  most  fre- 
quently practiced,  the  history  of  the  majority  of  cases  has  certainly 
not  made  sufficient  offset  to  balance  the  risks  incurred.  It  is  cer- 
tainly true  enough  that  cases  occur  where  it  would  seem  that 
nothing  else  can  be  done.  But  when  sections  are  made  of  healthy 
nerve  cords  one  should  be  well  satisfied  that  he  has  an  otherwise 
irremediable  condition  in  the  nerve  substance  external  to  his  line  of 
section. 

For  these  operations,  and  the  mode  of  performing  them,  see 
chapter  on  Resections. 

Anomalous  Nervous  Disturbances  from  Diseased  Teeth. — As  a 
continuation  of  the  subject  of  reflex  or  associate  disturbances,  it  may 
not  be  without  advantage  to  add  the  following  series  of  clinical  ob- 
servations, abstracted  from  various  journals,  which,  from  time  to 
time,  have  fallen  under  my  observation  : 

"  Dr.  B.,  a  dentist,  consulted  me  in  reference  to  his  eyes,  which 
'  would  not,'  as  he  expressed  it,  '  focus  together ;'  could  see  dis- 
tinctly with  either  eye,  but  not  with  both  at  once ;  was  unable,  in 
consequence,  to  practice  his  profession ;  had  consulted  several  phy- 


NEURALGIA. 


459 


sicians;  been  blistered,  cupped,  and  had  various  applications  made 
to  the  eye,  but  it  was  gradually  growing  worse.  The  pupil  of  the 
right  eye  was  very  much  enlarged. 

"I  pronounced  a  carious  and  diseased  first  superior  molar  to  be 
the  exciting  cause.  It  was  extracted,  with  almost  immediate  relief 
and  a  permanent  cure."  (  White.) 

Facial  Pai^alysis. — Dr.  Chas.  Bacon  reported  to  the  New  York 
State  Medical  Society  the  following  interesting  case  of  facial 
paralysis : 

"The  paralysis  occurred  first  on  the  left  side,  and  was  caused 
probably  by  irritation  of  the  facial  or  seventh  nerve,  by  the  erup- 
tion of  the  dens  sapientiae  of  the  upper  maxilla  of  the  same  side, 
and  exposure  to  cold.  The  swollen  gum  was  freely  excised,  mus- 
tard pediluvia  were  employed,  active  catharsis  procured,  and  the 
camphorated  liniment  with  tincture  of  opium  applied  to  the  mas- 
toid region  and  to  the  angle  of  the  jaw,  and  subsequently  electro- 
magnetism  to  the  same  region  was  resorted  to,  followed  by  a 
blister  to  the  mastoid  region,  the  denuded  surface  produced  by  it 
being  sprinkled,  twice  a  day  for  two  days,  with  one-eighth  of  a  grain 
of  strychnine,  and  then  a  few  doses  (fifteen  drops)  of  a  solution  of 
three  grains  of  strychnine  in  §i  of  alcohol,  were  taken.  At  the  end 
of  some  seventeen  months  the  paralysis  had  entirely  disappeared. 
For  about  ten  months  the  patient  enjoyed  uninterrupted  good  health, 
when  he  was  again  attacked  with  facial  palsy  of  the  right  side.  The 
gum  of  this  side  was  swollen.  A  treatment  somewhat  similar  to 
that  pursued  in  the  first  attack  was  directed.  At  the  period  when  the 
report  was  drawn  up,  about  four  weeks  from  the  date  of  the  second 
attack,  the  paralysis  was  lessened  in  extent,  and  the  general  health 
of  the  patient  was  good.  The  gum  was  less  swollen  but  the  tooth 
had  not  yet  made  its  appearance." 

"Neuralgia  with  Deafness,  cured  instantaneously  by  the  Extrac- 
tion of  a  Tooth. — M.  Ed.  Yautier  records  {Gaz.  des  Hopit.)  a  case  of 
this.  The  subject  of  it  was  a  very  nervous,  slender  woman,  who 
had  suffered  for  about  four  months  with  intense  neuralgic  pains, 
radiating  through  almost  all  the  teeth,  and  also  the  muscles  of  the 
anterior  region  of  the  left  side  of  the  head.  There  was  constant 
lachrymation  of  the  left  eye,  and  from  the  moment  of  the  attack 
complete  deafness  in  the  ear  of  the  same  side.  A  number  of  phy- 
sicians had  been  consulted,  and  sulphate  of  quinia,  flying  blisters, 
and  atropia,  in  succession,  tried  without  giving  relief 

"  When  seen  by  Dr.  B.  she  was  suffering  severely ;  had  long  been 


460  ORAL  DISEASES  AND   SURGERY. 

deprived  of  sleep,  and  could  not  chew  her  food.  The  teeth  were 
examined  with  care,  but  no  one  could  be  found  carious.  The  wisdom 
tooth  on  the  left  side  seemed,  however,  slightly  painful  on  being 
touched,  and  loose.  She  was  advised  to  have  this  tooth  extracted, 
but  with  some  temper  refused.  However,  some  days  afterward,  her 
physician  again  advising  it,  she  consented,  and  the  tooth  was  ex- 
tracted by  M.  Yautier.  The  pains  at  once  ceased,  and  her  hearing 
was  restored.  A  month  has  since  elapsed  without  any  return  of  her 
complaint.     She  seems  to  be  permanently  cured."  {Dental  Cosmos.) 

"  Cases  of  Convulsions  arising  from  Carious  Teeth. — St.  Bar- 
tholomew's Hospital. — Notes  furnished  by  Mr.  Alfred  Coleman: 

"  Case  I. — L.  C.  G.,  aged  seven  years,  a  moderately  healthy-looking 
child  up  to  the  age  of  four  years  and  a  half,  when  he  had  scarlatina 
severely,  followed  by  glandular  swellings.  About  four  months  since 
he  was  observed  to  avoid  using  his  fingers,  and  would  attempt  to 
take  up  a  cup  between  the  backs  of  his  two  hands,  for  which  his 
mother,  thinking  it  was  a  childish  trick,  always  scolded  him  and 
tried  to  make  him  take  it  up  in  the  proper  way,  but  without  much 
success.  Fancying  his  right  arm  was  diminishing  in  size,  she  took 
him  to  Mr.  Coote,  who  sent  him  to  Mr.  Coleman  to  examine  his 
mouth.  This  was  on  a  Saturday.  ^  In  the  afternoon  of  the  same 
day,  after  having  been  seen  by  Mr.  Coleman,  the  child  was  attacked 
with  a  fit  of  what  his  mother  described  as  shivering  in  the  right 
arm,  the  arm  and  fingers  being  drawn  up  as  well  as  convulsed ;  his 
speech  also  seemed  affected.  Shortly  afterward,  this  was  succeeded 
by  another  fit  of  the  same  character,  which  commenced  with  a  feeling 
of  pins  and  needles  in  the  right  shoulder,  extending  to  the  arm  and 
hand.  From  the  Saturday  to  the  Sunday  evening  inclusive  he  had 
ten  such  attacks.  On  the  Monday  he  had  an  epileptic  fit,  which 
lasted  two  hours,  soon  afterward  followed  by  another,  which  did  not 
last  so  long. 

"  Wednesday. — The  child  has  had  no  more  epileptic  fits  ;  but  the 
lesser  seizures  still  continue,  occurring  very  frequently.  He  appears 
much  alarmed  at  them.  His  mouth  and  cheek  are  drawn  up  during 
a  fit,  and  he  cannot  speak;  but  says  'Mother,  it  is  going,' as  the 
attack  is  leaving  him.  On  this  day  Mr.  Coleman  extracted  his  four 
temporary  second  molar  teeth,  all  of  which  were  decayed,  but  had 
given  him  little  or  no  pain. 

"May,  1861. — Has  remained  perfectly  free  from  the  before-men- 
tioned seizures  since  the  removal  of  the  teeth  until  within  the  last 
two  days,  during  which  he  has  had  seven  slight  attacks.     One  of 


•    NEURALGIA.  461 

the  first  temporary  teeth  was  found  to  be  carious,  and  it  was  re- 
moved about  a  week  after  this.  His  mother  called  and  stated  that 
he  had  one  very  slight  attack  since  the  removal  of  the  tooth  ;  she 
promised  to  bring  him  should  a  second  occur,  but  neither  mother 
nor  child  has  been  seen  since  that  time. 

"  Case  II. — M.  J.,  aged  about  twenty-three  years;  is  healthy-look- 
ing, and  enjoys  very  good  health ;  suffers  much  from  toothache,  and 
during  the  fits  has  a  tingling  sensation  in  the  palms  of  his  hands 
and  soles  of  his  feet,  but  especially  in  the  left  arm.  Several  of  his 
teeth  were  decayed,  but  not  so  much  so  as  to  require  removal ;  they 
were  filled  with  gold,  since  which  he  has  had  no  return  of  pain  or 
the  accompanying  sensations." 

"A'mau7'osis  consequent  on  Acute  'Abscess^  of  the  Antrum,  pro- 
duced hy  a  Carious  Tooth. — By  S.  J.  A.  Salter,  M.B.,  F.L.S.,  Sur- 
geon-Dentist to  Guy's  Hospital.  Read  before  the  Royal  Medical 
and  Chirurgical  Society. — The  case  upon  which  this  paper  was 
based  was  one  of  unusual  severity,  and  of  exceptional  complications. 
The  patient,  a  young  woman  twenty-four  years  of  age,  was  attacked 
with  violent  toothache  in  the  right  upper  first  molar,  which  was  fol- 
lowed by  enormous  swelling  of  the  side  of  the  face,  and  intense 
pain.  The  eyeball  then  became  protruded,  and  she  soon  after  per- 
ceived that  the  eye  was  blind.  Shortly  after  the  establishment  of 
these  symptoms,  '  abscess'  of  the  antrum  pointed  at  the  inner  and 
then  at  the  outer  canthus,  and  a  large  discharge  of  pus  at  both  ori- 
fices followed  ;  these  orifices  soon  closed,  and  the  general  symptoms 
of  the  part  continued  unchanged— the  swelling  of  the  face,  protru- 
sion of  the  globe,  and  blindness.  This  state  of  things  lasted  for 
about  three  weeks,  when  the  patient  was  sent  to  Guy's  Hospital,  and 
admitted. 

"At  this  time  the  patient  exhibited  hideous  disfigurement  from 
swelling  of  the  face,  oedema  of  the  lids,  and  lividity  of  the  surround- 
ing integument.  Upon  examining  the  mouth,  it  was  found  that  the 
carious  remains  of  the  first  upper  right  molar  appeared  to  1  -  asso- 
ciated with  and  to  have  caused  the  disease.  Together  with  the 
other  contiguous  carious  teeth,  this  was  removed,  and  led,  by  an  ab- 
sorbed opening,  into  the  floor  of  the  antrum.  The  hemorrhage 
which  followed  the  operation  was  discharged  partly  through  the 
nose  and  partly  through  the  orifices  in  the  cheek,  as  well  as  from 
the  tooth-socket,  showing  a  common  association  of  these  openings 
with  the  antrum.  The  condition  of  the  eye  constituted  the  most 
important  symptom,   and   the   most   distressing.     The   sight   was 


462  ORAL  DISEASES  AND   SURGERY. 

utterly  gone ;  the  globe  prominent  and  everted.  There  was  general 
deep-seated  inflammation  of  the  fibrous  textures  of  the  eye.  The 
pupil  was  large  and  rigidly  fixed  ;  it  did  not  move  co-ordinately  with 
the  other  under  any  circumstances.  Some  abatement  of  the  symp- 
toms followed  the  extraction  of  the  tooth  ;  but  it  was  soon  found  that 
there  was  a  considerable  sequestrum  of  dead  bone,  which  was  re- 
moved. The  necrosis  involved  the  front  part  of  the  floor  of  the 
orbit,  the  upper  cheek  portion  of  the  superior  maxilla,  with  the  infra- 
orbital foramen,  and  a  large  plate  of  bone  from  the  inner  (nasal) 
wall  of  the  antrum.  The  removal  of  the  dead  boae  was  followed 
by  the  immediate  and  complete  cessation  of  all  inflammatory  symp- 
toms ;  but  the  eye  remained  sightless,  and  the  pupil  rigidly  fixed. 
About  five  weeks  after  the  removal  of  the  dead  b«ne,  it  was  noticed 
that  the  pupil  of  the  affected  eye  moved  with  that  of  the  other, 
under  the  influence  of  light,  though  vision  in  it  had  not  returned. 
The  eye  was  frequently  examined  at  this  stage  with  the  ophthalmo- 
scope. All  the  structures,  including  the  retina,  appeared  healthy, 
except  the  termination  of  the  optic  nerve,  which  was  perfectly  white 
and  anaemic,  while  that  of  the  other  eye  was  pink  and  natural. 

"  The  author  referred  to  two  other  cases  essentially  similar  to  his 
own.  The  first  (unpublished)  occurred  in  the  practice  of  Mr.  Pol- 
lock, of  St.  George's  Hospital.  The  patient  had  intense  inflamma- 
tion of  the  entire  maxillary  region  on  one  side,  caused  by  a  carious 
tooth.  It  implicated  the  whole  face  and  the  contents  of  the  orbit, 
but  was  not  attended  by  '  abscess'  of  the  antrum  or  necrosis  of  bone. 
The  inflammation  completely  ceased  on  the  removal  of  the  tooth, 
but  the  sight  was  permanently  lost ;  the  pupil  was  at  first  fixed,  but 
afterward  moved  with  that  of  the  other  eye. 

"Another  example,  closely  resembling  these,  was  published  by 
Dr.  Briick,  in  Casper's  '  Wochenschrift'  for  1851.  It  was,  however, 
more  chronic,  and  the  loss  of  vision  was  only  temporary. 

"  The  author  concluded  his  paper  by  suggesting  that  the  serious 
ophthalmic  symptoms  depended  on  the  nerves  of  the  eye  being  in- 
volved in  a  plastic  inflammation  in  their  course,  external  to  the  skull 
and  before  their  distribution ;  that  the  optic  nerve  was  permanently 
damaged,  as  shown  by  the  permanent  blindness  ;  and  that  the  third 
nerve  was  temporarily  implicated,  as  shown  by  the  temporary  fixed- 
ness of  the  pupil ;  and  the  eversion  of  the  eye  from  the  first  seemed 
to  indicate  that  the  sixth  nerve  was  less  or  not  at  all  involved. 
Finally,  the  author  left  it  an  open  question  whether  the  anasmia  of 
the   optic   nerve,   as   displayed   by  the   ophthalmoscope,  is   to  be 


NEURALGIA.  453 

looked  upon  as  a  cause  or  consequence  of  its  suspended  function." 
(^Lancet.) 

Sympathetic  Action. — In  the  course  of  an  article  on  "Amaurosis 
and  other  Disorders  of  the  Eye,  resulting  from  Injury  of  the  Terminal 
Branches  of  the  Fifth  Pair  of  Nerves,"  in  the  Amer.  Jour,  of  the 
Med.  Sci.  for  July,  Dr.  D.  Lente  gives  the  following  interesting 
observations  upon  the  sympathetic  relations  of  the  teeth  and  eye : 
"  Middlemore  says  '  amaurosis  may  arise  during  the  period  of  den- 
tition ;  it  may  take  place  from  the  irritation  of  a  carious  tooth  ;  from 
laceration  or  other  injury  of  the  supraorbitary  nerve.'  He  relates 
a  case  in  which  Mr.  Howship  removed  an  encysted  tumor  from  the 
scalp,  which  produced  'marked  and  permanent  improvement  in 
vision.'  Another  case,  in  which  M.  Demours  removed  a  tumor  from 
the  neighborhood  of  the  eye,  and  thus  produced  amaurosis.  Another 
from  the  Edinburgh  Medical  and  Surgical  Journal,  '  which  would 
appear,'  he  says,  'to  prove  that  wounds  of  the  infraorhitary  nerve 
may  restore  the  sight  of  an  eye  which  has  long  been  lost  from  an 
amaurotic  affection.'  'A  man  was  affected  with  perfect  gutta  serena 
of  the  right  eye,  and  had  the  sight  of  the  eye  restored,  he  thinks, 
in  consequence  of  receiving  a  smart  blow  in  the  neighborhood  of  the 
infraorhitary  nerve  of  the  right  side  of  the  face.'  Another  still  more 
striking  case,  in  which  a  person  received  '  a  wound  just  above  the 
right  eyebrow  from  a  piece  of  glass,  which  was  removed  imme- 
diately after  the  accident.'  When  the  wound  had  healed,  'the  sight 
of  the  right  eye  was  very  nearly  lost ;  he  has  had  a  painful  sensation 
in  the  neighborhood  of  the  cicatrix,  and  a  singular  sense  of  creeping, 
and  pinching  and  quivering  of  the  upper  eyelid  and  the  integuments 
of  forehead.'  '  I  made  a  free  incision  of  the  cicatrix  down  to  the  bone, 
and  all  uneasiness  at  once  ceased,  and  the  eye,  shortly  after,  assumed 
its  healthy  character  and  functions,  and  vision  was  loermanently 
restored.''  Lawrence;  after  relating  two  or  three  cases  of  amaurosis 
following  wounds  and  the  formation  of  cicatrices  over  the  brows, 
remarks  :  '  It  is  still  a  matter  of  doubt  whether  injury  of  the  frontal 
nerve  may  cause  amaurosis.'  And  yet,  he  adds,  'injury  or  other 
irritation  of  the  trigeminus  may  bring  on  impaired  vision  or  amau- 
rosis.' '  The  sympathy  between  the  trigeminus  and  the  immediate 
nervous  apparatus  of  vision  affords  the  only  explanation  of  some 
apparently  obscure  cases,  in  which  amaurosis  seems  to  have  de- 
pended on  a  carious  tooth,  or  on  some  other  local  affection  seated 
in  the  head.' 

"  The  following  remarks  by  Marshall  Hall  were  reported  in  the 


464  ORAL  DISEASES  AXD   SURGERY. 

London  Lancet  for  183*7-38:  '  These  experiments,'  alluding  to  those 
made  by  Magendie,  '  are  not  the  only  evidence  we  possess  of  the 
influence  of  the  fifth  pair  on  vision.'  '  In  an  interesting  case  under 
my  own  care,  a  partial  amaurosis  of  the  right  eye  has  arisen  ap- 
parently from  the  caries  of  the  upper  canine  tooth  of  the  right  side.' 
It  was  augmented  by  unsuccessful  efforts  at  extraction.  It  has  not 
ceased,  however,  since  extraction  was  effected.  '  These  facts,'  says 
he,  speaking  of  this  and  other  cases,  '  with  the  similar  results  from 
wounds  or  tumors  of  the  supraorbitar  branch  of  the  fifth,  appear  to 
me  to  confirm  the  extraordinary  experiments  of  Magendie.'  Hennen 
says  :  '  I  have  met  with  one  or  two  cases  of  amaurosis  from  wounds 
of  the  supraorbital  nerve.'  'Scarpa,'  he  says,  'doubts  of  the  pos- 
sibility of  the  cure  of  amaurosis  from  this  cause,  and  mentions  Val- 
salva's case  as  the  only  one  on  record.'  Mr.  Hey,  however,  states 
another  in  the  Medical  Observations  and  Liquiries,  vol.  v.  M. 
Larrey  mentions  another,  Vicq  d'Azyr,  who  gives  a  case  of  amau- 
rosis from  a  wound  of  this  nerve,  in  the  Histoire  de  la  Sociele 
Royale  de  Medecine,  Annee,  1776,  says  he  has  'since  divided  this 
nerve  in  quadrupeds,  but  without  producing  any  such  effect.' 

"  That  defective  vision  may  result  as  the  direct  consequence  of 
irritation  of  the  terminal  branches  of  the  fifth  pair  may  also  be  in- 
ferred from  the  effects  of  remedial  applications  to  these  nerves,  and 
from  the  phenomena  observed  to  follow  irritations  and  injuries  of 
other  branches  not  so  immediately  connected  with  the  eye.  Some 
of  these  instances  it  will  be  proper  to  mention.  A  friend  of  the 
writer,  a  distinguished  surgeon  of  New  York  City,  was  incapaci- 
tated for  business  by  violent  neuralgia  of  the  face  ;  after  having  suf- 
fered some  time  with  it,  he  noticed  that  one  of  his  molar  teeth  was 
defective,  and  went  to  a  dentist  to  have  it  examined  ;  not  supposing, 
however,  that  it  had  any  connection  with  his  neuralgia,  since  it  gave 
him  no  pain.  Its  removal  was  advised ;  the  operation  was  scarcely 
over  before  the  doctor  experienced  complete  relief  from  his  excessive 
pain.  '  I  felt,'  he  said,  '  as  if  I  could  have  shouted  for  joy.'  A  lady, 
a  short  time  since,  applied  to  me  to  extract  a  tooth  for  her  little 
daughter,  which,  she  said,  had  been  causing  her  excruciating  pain 
day  and  night ;  but,  on  examination,  I  could  discover  no  defect,  and 
prescribed  some  anodyne  remedy,  which  gave  only  temporary  relief. 
A  dentist  was  called  in,  who  also  declined  extracting  a  sound  tooth ; 
but  on  a  second  visit,  and  a  closer  examination,  detected  an  unsound 
tooth  at  some  distance  from  the  offending  one,  and  extracted  it.  The 
pain  instantly  ceased,  and  did  not  recur.     Mackenzie  relates  a  re- 


NEURALGIA.  4^15 

markable  case  in  point.  A  man  had  violent  neuralgia  of  the  eye 
soon  succeeded  by  amaurosis,  and  continuing,  notwithstanding- 
various  treatment,  from  the  autumn  of  1825  until  the  beginnino-  o"f 
1827.  At  this  time  M.  Galenzowski,  to  whom  he  applied,  'found 
vision  of  the  left  eye  lost  and  the  pupil  dilated.  He  extracted  a 
decayed  tooth  from  the  left  upper  jaw,  and,  to  his  astonishment, 
and  that  of  the  patient,  found,  attached  to  its  root,  a  splinter  of  wood, 
supposed  to  have  been  originally  attached  to  a  toothpick  of  wood. 
Nine  days  after  the  patient  had  entirely  regained  his  sight.^  Mac- 
kenzie relates  another  equally  remarkable  case,  occurring  in  the 
practice  of  Dr.  Tan  Zandt,  of  St.  Louis,  '  of  a  young  man  affected 
with  complete  amaurosis,  excited  by  the  persistence  of  two  decid- 
uous teeth.  As  soon  as  they  were  extracted,  the  patient  looked  up 
as  if  terriiied,  and  found  his  vision  restored.''  'Morgagni,  Notta, 
Deval,  Tavignot,  and  others,'  says  M.  Echeverria,  'have  known 
amaurosis  to  be  caused  by  neuralgia,  and  to  disappear  as  soon  as 
the  neuralgia  was  cured.'  (The  italics  in  the  above  references  are 
my  own. — L.).  Such  cases  as  these  might  be  multiplied,  but  it  is 
scarcely  necessary."  ***** 

"  There  are  several  features  in  the  rather  remarkable  history  of 
Antoinette  H.  which  require  some  notice  before  concluding  this 
article.  It  was  objected  by  a  very  distinguished  oculist,  to  whom 
the  case"  [one  in  which  part  of  a  gun  cap  was  accidentally  driven 
into  the  pericranium  of  the  left  side  of  the  forehead,  producing 
amaurotic  and  other  disturbance]  "  was  related,  soon  after  its  occur- 
rence, that  the  wound,  being  on  the  left  side,  the  amaurotic  symp- 
toms should  have  affected  the  left  eye,  and  not  the  right.  But  this 
is  not  more  remarkable  than  that  disease  in  one  tooth  should  occa- 
sion a  violent  toothache  in  another  perfectly  sound ;  or  that  irrita- 
tion of  the  nerves  of  the  stomach  by  acidity  should  induce  violent 
neuralgia  of  the  supraorbital  nerve;  or  that  an  irritating  application 
to  the  mucous  surface  of  the  eyelid  should  determine  also  an  imme- 
diate irritation  of  the  Schneiderian  membrane,  succeeded  by  violent 
sneezing ;  or  that  simply  touching  the  memhrana  tympani  with  a 
probe  should  sometimes  give  immediate  relief  to  a  toothache."' 
(Dental  Cosmos.) 

"Facial  Paralysis.— Dv.  Coale  reports  the  following  case.  The 
patient  was  a  healthy,  w^ell-regulated  girl,  aged  eighteen,  who  at  first 
noticed  that  her  face  w^as  somewhat  stiff,  and  in  twenty-four  hours 
completely  paralyzed  on  the  left  side.  There  was  great  distortion 
on  laughing  or  talking,  a  staring  left  eye,  and  tenderness  of  the 

30 


466  ORAL  DISEASES  AXD  SURGERY. 

whole  left  side  of  the  face.  The  tongue  was  not  at  all  affected,  the 
disease  being  confined  to  the  portia  dura.  No  cause  could  be  found 
for  it,  unless  it  were  that  she  had  defective  teeth  in  each  jaw,  as 
much,  however,  on  one  side  of  the  mouth  as  the  other.  The  treat- 
ment consisted  of  leeches  to  the  place  of  exit  of  the  nerves,  strych- 
nia, etc.,  but  with  no  benefit.  After  the  lapse  of  three  weeks,  she 
was  advised  to  have  her  carious  teeth  removed,  and  thirteen  were 
accordingly  extracted.  This  was  followed  by  manifest  improve- 
ment in  the  course  of  five  da3'S.  Electro-galvanism  was  then  gently 
employed,  and  the  patient  recovered. 

"  Dr.  Tyler  said  that  several  years  ago  he  had  under  his  care  a 
lady  with  severe  sciatica,  for  which  all  the  usual  remedies  had  been 
tried  in  vain.  Finding  that  she  had  several  decayed  teeth,  he  ex- 
tracted four  or  five  of  them,  with  benefit.  The  remainder  were  sub- 
sequently drawn,  after  which  the  patient  had  no  more  pain. 

"  In  1853,  a  boy,  aged  nineteen,  was  brought  to  the  New  Hamp- 
shire Asylum  in  a  state  of  mania.  Dr.  Tyler  ascertained  that  he 
had  had  a  tooth  extracted  some  time  previous,  and  that  one  of  the 
fangs  had  broken  off,  and  remained  in  the  jaw.  Suppuration  took 
place,  the  pus  discharging  outwardly,  and  the  boy  was  suddenly  at- 
tacked with  mania.  The  fang  was  removed.  The  fistulous  opening 
closed,  and  the  patient  quickly  recovered  from  his  mania. 

"  In  another  case  of  mania,  the  patient  being  a  young  lady,  sev- 
eral decayed  teeth  were  removed.  The  patient  remained  to  some 
extent  under  the  influence  of  the  ether,  which  was  given  at  the  oper- 
ation, for  twenty-four  hours.  After  that  she  was  cured  of  the  mania." 

Insanity  is  sometimes  caused  by  Diseased  Teeth. — James  Tru- 
deau,  M.D.,  of  Paris,  says:  "  M. Esquirol  told  me  that  he  had  cured 
a  young  lady,  who  was  insane,  of  her  mania  by  the  extraction  of 
her  second  molar  tooth,  which  was  preventing  the  growth  of  a  wis- 
dom tooth." 

Epilepsy  from  Diseased  Teeth. — Dr.  Rush  ("Med.  Inq.  and 
Obs.")  says:  "  Some  time  in  the  year  1801,  I  was  consulted  by  the 
father  of  a  young  gentleman  in  Baltimore,  who  had  been  afflicted 
with  epilepsy.  I  inquired  into  the  state  of  his  teeth,  and  was  in- 
formed that  several  of  them  in  his  upper  jaw  were  much  decayed. 
I  directed  them  to  be  extracted,  and  advised  him  afterward  to  lose 
a  few  ounces  of  blood  at  any  time  that  he  felt  the  premonitory  symp- 
toms of  a  recurrence  of  his  fits.  He  followed  my  advice,  in  conse- 
quence of  which  I  had  lately  the  pleasure  of  hearing,  from  his 
brother,  that  he  was  perfectly  cured." 


NEUItALGIA. 


467 


Paralysis  from  Dental  Irritation.— The  American  Journal  of 
Dental  Science,  New  Series,  vol.  i.  p.  504,  quotes  from  the  London 
Lancet,  as  reported  by  J.  L.  Levison,  of  Brighton,  the  following 

case  :  "  Miss ,  a  young  lady,  was  brought  in  a  carriage  to  my 

residence,  to  have  her  mouth  examined.  On  being  removed,  she 
was  supported  by  a  lady  on  one  side,  and  a  man-servant  on  the 
other,  and  her  entire  muscular  system  seemed  paralyzed.  Her  Ics 
trailed  on  the  ground  like  useless  appendages;  her  arms,  when 
raised,  fell  powerless  immediately,  when  unsupported ;  and  even  the 
muscles  of  the  tongue  were  paralyzed,  and  in  her  efforts  to  speak, 
this  important  organ  remained  in  a  quiescent  state.  On  examining 
the  mouth,  I  perceived  a  dens  sajnentise  of  the  lower  jaw  very  cari- 
ous, and  deeply  imbedded  in  the  temporal  muscle,  just  below  the 
ridge  of  the  coronoid  process,  in  which  locality  there  was  extensive 
inflammation.  I  suggested  the  removal  of  the  tooth ;  and  though 
I  had  anticipated  some  advantage  from  the  operation,  the  actual  re- 
sult astonished  me.  She  instantly  obtained  the  free  use  of  her 
tongue,  which  she  immediately  used  to  communicate  an  important 
fact,  viz.,  that  ever  since  the  tooth  I  had  extracted  had  been  making 
its  way  through  the  gum,  she  could  date  the  gradual  loss  of  power 
over  her  limbs,  etc.  I  saw  her  about  a  month  afterward ;  she  could 
then  use  her  hand  and  arm — she  was  writing  a  letter !  Since  then 
I  have  not  heard  what  progress  she  has  made." 

Sir  Astley  Cooper,  in  speaking  of  the  effects  of  slight  irritation, 
says  :  "  M.  Toulmin,  of  Hackney,  attended  a  lady  on  account  of  her 
suffering  unusually  from  a  diseased  tooth,  and  she  appeared  to  be 
afflicted  with  hemiplegia.  M.  Toulmin  extracted  the  tooth,  and  in  a 
short  time  the  paralytic  affection  entirely  subsided." 

Catalepsy  from  Toothache. — The  Dental  Recorder,  vol.  viii.  No. 
1,  p.  197  (1854),  quotes  from  The  Stethoscope,  as  reported  by  Dr. 
Huton,  the  following  case: 

"Willis,  a  plowboy  (October  last),  was  complaining  of  toothache 
early  in  the  morning ;  half  an  hour  after  commencing  work,  was  ob- 
served lying  a  short  distance  from  the  plow,  apparently  dead.  He 
was  carried  to  the  house,  nearly  a  mile,  and  the  doctor  (five  miles 
distant)  sent  for.  In  the  belief  that  the  effect  might  be  produced 
through  the  dental  nerve,  the  tooth  was  extracted,  when  the  boy  im- 
mediately got  up  and  expressed  himself  as  well  as  ever ;  and  has 
continued  well  since.  He  had  been  an  unusually  healthy  boy,  and 
had  never  had  a  physician  to  see  him  before." 

The  following  interesting  and  suggestive  cases  were  collated  by 


468  ORAL  DISEASES  AXD  SURGERY. 

Dr.  Abraham  Robertson,  of  Tirgiuia,  and  published  in  the  Dental 
Cosmos : 

"  Chorea  is  sometimes  caused  by  Dental  Irritation. — The  Ameri- 
can Journal  of  Dental  Science,  vol.  vi.,  New  Series,  p.  146,  quotes 
from  the  Dental  Xeics  Letter,  the  following 

"  Case. Dr.  Billard  says,  after  an  examination  of  the  case,  which 

was  one  of  what  is  commonly  called  St.  Vitus's  dance,  that  he  found 
several  stumps  in  both  jaws,  the  gums  entirely  covering  some  of 
them,  and  on  pressure  of  the  same,  it  caused  her  great  pain,  and  pus 
exuded  on  the  slightest  pressure.  *****!  proceeded  to 
give  ether,  and  it  took  a  double  quantity  to  make  her  insensible  to 
pain.  I  then  took  out  eight  stumps  and  some  small  pieces  of  dead 
alveoli,  which  had  caused  a  continuous  irritation  of  the  parts.  Since 
that  time,  the  author  states,  the  paroxysms  grew  less  frequent,  and 
now  the  patient.  Miss  L.,  enjoys  her  usual  health." 

^'  Erysipelas  from  a  Diseased  Tooth;  Death  of  Patient. — The  fol- 
lowing case  was  reported  by  Dr.  Thompson  of  the  '  Seaman's  Re- 
treat' (N.  y.),  and  furnished  to  the  New  York  Medical  Gazette,  in 
which  it  was  published,  vol.  iii.  p.  263  (1852),  by  Dr.  Sayer  of 
that  city. 

"Case. — Charles  Lunt,  aged  thirty,  Swede,  arrived  June  28  from 
Havre.  Admitted  into  hospital,  at  the  date  just  mentioned,  for  an 
inflammatory  tumefaction  of  left  check  and  parotid  gland,  of  three 
da3's'  standing,  as  patient  stated,  from  toothache,  with  which  he  had 
been  annoyed  for  several  days  previous  to  the  swollen  face.  Patient 
otherwise  healthy  and  of  a  stout,  robust  appearance. 

"  On  admission,  the  tooth  of  which  he  complained  was  extracted ; 
there  discharged,  in  cutting  about  the  tooth,  a  considerable  quantity 
of  fetid  pus.  After  extraction  of  the  tooth,  a  powder  of  calomel  and 
rhei  was  given,  and  an  emollient  poultice  applied  to  the  face.  The 
latter  was  continued,  and  antiphlogistic  remedies  pursued,  but  with- 
out much  relief  to  the  pain  or  reduction  of  the  swelling — when,  after 
several  days,  the  inflammation  assumed  an  erysipelatous  character. 
The  affected  parts  were  now  painted  with  a  strong  solution  of  nitrate 
of  silver,  evaporating  lotions  applied,  and  the  remedies  indicated  by 
the  constitutional  symptoms  administered  internally.  This  treatment 
persisted  in,  the  inflammation,  in  a  short  time,  greatly  subsided,  and 
these  promised  hopes  of  a  speedy  recovery.  Suddenly,  however, 
the  erysipelas  commenced  to  spread,  and  the  accompanying  symp- 
toms to  increase  in  violence,  until  the  palpebra  of  the  (left)  eye  and 
parts  adjacent  became  involved.     As  the  disease  advanced,  pus  was 


NEURALGIA. 


469 


formed  in  several  places,  which  was  evacuated.  The  conjunctiva, 
partaking  of  the  contiguous  inflammation,  became  swollen  and  oede- 
matous.  The  other  tissues  of  the  eye  also  soon  became  involved, 
and  now  occurred  delirium  and  other  symptoms  indicative  of  the  ex- 
tension of  the  inflammation  to  the  brain.  This  being  apprehended, 
a  vigorous  revulsive  antiphlogistic  course  of  treatment  was  adopted, 
but  without  much  relief  to  the  patient.  The  symptoms  just  alluded 
to  continuing,  and  gradually  increasing  in  violence,  the  disease  on 
the  fourth  day  of  their  occurrence  proved  fatal." 

"  Vicarious  Menstruation  from  Decayed  Teeth. — Dr.  Rush,  '  Med. 
Obs.  and  Inqrs.,'  says,  in  the  second  number  of  a  work,  entitled 
'  Bibliotheque  Gerraanique  Medico-Chirurgicale,'  published  in  Paris 
by  Dr.  Bluver  and  Dr.  Delaroche,  there  is  an  account  published  by 
Dr.  Siebold  of  a  young  woman  who  had  been  affected  for  several 
months  with  great  inflammation,  pain,  and  ulcers  in  her  right  upper 
and  lower  jaws,  at  the  usual  time  of  the  appearance  of  the  catamenia, 
which  at  that  period  were  always  deficient  in  quantity.  Upon  in- 
specting the  seats  of  these  morbid  affections  the  doctor  discovered 
several  of  the  molars  in  both  jaws  to  be  decayed.  He  directed  them 
to  be  drawn,  in  consequence  of  which  the  woman  was  relieved  of 
the  monthly  disease  in  her  mouth,  and  afterward  had  a  regular 
discharge  of  her  catamenia." 

"In  the  Western  Journal  of  Medical  and  Physical  Science  for 
1838,  Dr.  S.  P.  Hullihen  reported  the  following 

"  Case. — Some  time  since  a  young  lady,  about  seventeen  years  of 
age,  applied  to  me  with  a  fungous  growth  in  each  of  the  second  molars 
of  the  lower  jaw,  which  had  assumed  rather  a  novel  character.  She 
stated  that  the  fungi  had  made  their  appearance  in  both  teeth  at  the 
same  time,  about  four  years  before,  and  that  for  the  last  two  years 
she  had  been  much  troubled  Mnth  a  bleeding  from  them,  which  took 
place  regularly  once  a  month,  and  continued  several  days.  She 
being  very  anxious  to  have  the  teeth  saved,  I  destroyed,  to  all  ap- 
pearance, the  morbid  growth,  and  plugged  the  teeth.  In  a  few  days 
they  became  sore  and  painful,  the  plugs  were  removed,  and  a  slight 
bleeding  commenced,  which  continued  three  or  four  days,  and  then 
the  tumors  entirely  disappeared.  I  was,  therefore,  induced  to  plug 
them  again ;  but  in  about  three  weeks  the  teeth  became  sore,  the 
plugs  were  removed,  and  a  bleeding  ensued  as  before.  I  now  sus- 
pected it  to  be  a  vicarious  menstruation,  and  mentioned  the  case  to 
the  family  physician.  At  his  request  I  plugged  them  again,  and  the 
result  was  precisely  as  before.     The  teeth  were  then  removed,  and 


470  ORAL  DISEASES  AND  SURGERY. 

the  patient  was  put  under  a  course  of  treatment  by  her  physician, 
which  effected  a  cure." 

"As  somewhat  allied  to  this  I  will  here  venture  the  opinion, 
although  I  have  no  case  in  mind  by  which  to  illustrate  the  fact,  that 
other  uterine  diseases  are  often  greatly  aggravated,  if  not  induced, 
by  this  same  cause.  And,  improbable  as  it  may  at  first  seem, 
especially  do  I  believe  this  to  be  true  in  relation  to  one  of  the  most 
common  afflictions — a  very  severe  affliction,  too — of  the  females  of 
our  country,  prolapsus  of  the  uterus. 

"  This  much  at  least  is  certain,  general  debility,  however  induced, 
is  a  most  common  cause  of  this  complaint,  and  I  have  often  ob- 
served that  when  it  is  not  complicated  with  other  diseases,  as  in- 
flammation, ulceration,  etc.,  it  may  readily  be  cured,  often  by  topical 
applications  only,  or  by  topical  applications  in  conjunction  with 
tonics  and  healthful  exercise  in  the  open  air,  and  sometimes  by  the 
tonics  and  exercise  without  any  topical  treatment,  or  perhaps  by 
Dr.  Meigs's  cure  alone,  of  '  six  miles  walk  a  day,  commencing  with 
small  doses,  and  increasing  according  to  ability;'  but  if  from  any 
cause  the  general  health  afterward  suffers,  and  debility  ensues,  a  re- 
currence of  the  prolapsus  will  also  be  likely  to  ensue.  And  since 
diseased  teeth,  by  the  nervous  irritation  they  produce,  by  the  de- 
rangement they  cause  in  the  digestive  and  respiratory  organs,  are 
most  common  and  potent  cause  of  such  debility,  they  must  neces- 
sarily be  the  cause,  indirectly  at  least,  of  this  kind  of  suffering." 

Epilepsy  connected  with  Dental  Irritation. — "I.  D.,  aged  thirteen, 
has  had  epilepsy  eighteen  months.  Had  no  fits  in  infancy,  no  nerv- 
ous affection  up  to  the  period  of  present  illness.  Family  history 
good.  First  attack  occurred  after  eating  some  crab-fish  for  supper. 
It  was  long  and  violent.  The  second  occurred  after  two  months' 
interval ;  cause  of  this  not  known.  The  third  occurred  in  fourteen 
days,  and  they  have  recurred  at  varying  intervals, — from  one  week 
to  three  weeks.  They  always  occur  during  the  night.  He  screams 
sometimes,  and  not  unfrequently  bites  his  tongue.  Latterly  his 
mother  has  noticed  that  some  days  he  rubs  his  left  cheek,  complain- 
ing of  faceache,  after  which  the  fit  follows.  He  is  a  healthy-looking 
boy;  tolerably  well-fleshed,  although  the  muscles  feel  somewhat 
flabby.  He  is  intelligent,  and  does  not  appear  to  have  suffered  in 
apprehension  or  memory ;  no  headache  nor  vertigo.  Organic  func- 
tions tolerably  well  performed ;  no  inter-paroxysmal  phenomena. 
On  examining  the  mouth,  there  is  to  be  seen  a  molar  tooth  consider- 
ably decayed,  with  a  swollen  gum  around  it,  and  partly  growing 


NEURALGIA. 


471 


over  into  the  cavity ;  it  is  not  very  tender  to  touch,  and  the  examin- 
ation does  not  give  rise  to  toothache.  On  questioning,  I  find  the 
sensation  which  the  boy  experiences  before  a  fit  does  not  seem  to  be 
one  of  pain,  but  rather  of  an  indefinite  uneasiness.  He  always  has 
a  fit  tlie  night  on  which  this  uneasiness  comes  on.  Has  never 
felt  it  during  the  day  ;  it  is  always  about  seven  to  eight  o'clock.  I 
desired  the  mother  to  have  the  tooth  extracted,  and  ordered  a  simple 
saline,  with  a  quarter  of  a  grain  of  belladonna,  to  be  taken  twice 
daily.  This  was  in  June.  The  tooth  was  extracted  next  day.  I 
saw  this  boy  once  a  fortnight  from  that  time  for  four  months,  but  he 
has  had  no  recurrence  of  the  fit. 

"  In  this  case  I  believe  an  unfelt  aura  commenced  about  the  gum 
surrounding  the  tooth,  and  was  not  recognized  till  some  degree  of 
inflammation  arose,  and  thus  a  modification  of  pain  became  asso- 
ciated with  the  aura,  and  directed  attention  to  it.  I  have,  at  the 
present  moment,  another  and  very  similar  case  to  this.  The  extrac- 
tion of  the  tooth  has  not  yet  been  performed,  so  that  I  cannot  give 
you  the  result.  When  epilepsy  occurs  in  children,  I  always  examine 
the  mouth,  with  the  twofold  view  of  observing  the  vault  as  to  height, 
narrowness,  etc.,  inasmuch  as  no  observation  about  the  cranial  de- 
velopment can  be  complete  without  such  examination,  and  of  ascer- 
taining whether  any  cause  of  eccentric  irritation  may  spring  from 
decayed  or  crowded  teeth.  I  would  observe  here  that,  later,  the 
dentes  sapientise  often  become  a  source  of  considerable  irritation, 
and,  therefore,  of  complication,  at  least  in  the  epilepsy  of  young 
persons."  (Dr.  J.  S.  Ramskill,  3Iedical  Times  and  Gazelle.) 


CHAPTER    XXXI. 

WOUNDS   OF   THE    MOUTH   AND   ASSOCIATE    PARTS. 

Wounds  of  the  mouth  and  associate  parts  have,  of  course,  the 
signification  of  wounds  in  general.  Thus,  some  are  of  an  incised 
character,  being  slits  or  incisions  made  accidentally  or  purposely  by 
sharp-edged  instruments ;  some  are  lacerated,  contused,  or  torn, 
being  made  by  dull  and  blunted  instruments ;  some  are  punctured, 
being  made  by  pointed  but  not  sharp  instruments ;  some  are  pene- 
trating, as  when  the  offending  agent  passes  through  the  lip  or  cheek 
into  the  oral  cavity.  A  wound  may  be  of  a  compound  or  complicated 
nature,  as,  for  example,  in  the  case  of  blows  or  falls,  which,  while 
they  cut  and  contuse  the  lip  or  cheek,  break,  at  the  same  time,  the 
teeth  or  fracture  the  jaw;  gunshot  injuries,  lacerating  or  simply 
puncturing  the  soft  parts,  comminuting  the  hard ;  bites  of  rabid 
animals,  introducing  a  virus ;  syphilitic  inoculations,  etc.  Compli- 
cations may  also  be  considered  as  embracing  hemorrhage  and  shock 
as  primary  associations ;  inflammation,  with  its  varied  phenomena, 
erysipelas,  pyaemia,  tetanus,  etc.,  as  secondary  associations. 

Every  wound  presents  a  first  indication.  If  an  individual  receives 
a  hurt  which  covers  the  injured  part  with  earth  or  other  foreign  sub- 
stance, such  substance  is  to  be  washed  or  taken  away  as  the  primary 
step.  If  hemorrhage  is  the  feature,  arteries  are  to  be  ligated,  or  other 
necessary  means  taken  to  control  such  bleeding.  If  shock  be  present, 
this  is  the  most  immediate  feature,  and  is  first  to  be  combated.  If 
a  rabid  or  poisonous  animal  has  inflicted  the  wound,  the  destruction 
of  the  virus  is  a  first  indication. 

Foreign  Particles. — To  remove  earth  or  similar  foreign  parti- 
cles, no  better  means  can  be  employed  than  the  simple  sponge  and 
water.  Holding  the  injured  part  over  a  basin,  squeeze  water  upon 
it  from  the  sponge  ;  if  the  particles  are  not  washed  away  with  the 
sponge  closely  applied,  let  it  be  lifted  aM^ay,  and  the  water  allowed 
to  fall  from  a  distance.  It  is  not,  as  a  rule,  at  all  necessary  to  per- 
mit the  sponge  to  come  directly  in  contact  with  a  wound.  Bodies 
which  may  not  be  washed  away,  no  matter  what  their  character, — 
(472) 


WOUXDS   OF  MOUTH  AND   ASSOCIATE  PARTS.     473 

splinters,  shot,  balls,  particles  of  powder,  specula  of  bone,  etc.,— 
are  to  be  removed  with  forceps,  scoop,  or  other  convenient  means 
the  rule  being  to  allow  nothing  to  remain  that  may  interfere  with 
the  process  of  repair. 

Hemorrhage. — A  first  matter  to  con.sider  in  hemorrhage  is  its 
character.  Is  it  arterial,  venous,  or  capillary  ?  An  arterial  hemor- 
rhage is  known  by  its  scarlet  color,  and  by  issuing  from  the  wound 
in  jets.  Hemorrhage  from  a  vein  is  dark,  and  has  a  gradual  and 
regular  flow.  Capillary  hemorrhage  is  an  oozing.  Arterial  hem- 
orrhage may  require  that  the  bleeding  vessel  shall  be  ligated.  To 
do  this  it  is  only  necessary  to  sponge  away  the  blood  until  the  vessel 
can  be  plainly  seen ;  it  is  then  to  be  taken  hold  of  by  the  forceps, 
or  caught  in  the  tenaculum,  and  a  strand  of  waxed  silk  thrown 
around  it.  In  tying  this  silk,  one  must  be  careful  that  he  shall  not 
break  his  strand  at  either  side  of  the  knot,  also  that  the  tightening 
shall  be  sufficient  to  cut  the  middle  and  inner  coats.  To  prevent 
tearing  the  vessel  from  its  bed  by  the  breaking  of  the  ligature,  the 
rule  of  holding  the  thumb  upon  the  strands  close  to  either  side  of 
the  artery  is  always  to  be  observed. 

After  ligating  a  vessel,  one  end  of  the  ligature  may  be  cut  off  and 
the  other  brought  out  from  between  the  edges  of  the  wound ;  this 
allows  of  an  easy  future  removal  of  the  knot. 

Torsion  of  a  bleeding  artery  is  a  favorite  mode  of  treatment  with 
many  surgeons.  The  end  of  the  vessel  is  to  be  caught  by  the  for- 
ceps, and  twisted.  The  author  of  the  mode  suggests  that  the  tor- 
sion be  continued  until  the  end  is  twisted  off. 

Acupressure  is  another,  and  a  very  common  method  of  treatment. 
A  steel  or  gold  needle  is  passed  beneath  the  vessel  in  such  manner 
as  to  tightly  compress  it  against  the  neighboring  parts. 

Pressure  by  pad  and  bandage,  when  a  hemorrhage  about  the  face 
will  not  yield  to  simpler  means,  is  a  very  satisfactory  way  of  treat- 
ment, and  one  entirely  reliable.  All  the  vessels  of  this  region  rest 
upon  a  bony  floor,  and  all  of  them,  at  certain  points,  are  sufficiently 
superficial  for  the  purpose, — the  facial,  at  the  notch  in  the  inferior 
maxillary,  in  front  of  its  angle;  the  temporal,  just  in  front  of  the 
ear  above  the  zygomatic  process ;  the  supraorbital,  at  the  notch  in 
the  orbit ;  the  infraorbital,  at  the  foramen  below  the  border. 

A  bandage  of  common  application  for  any  of  these  vessels  is  the 
crossed  or  knotted  circular.  A  glance  at  the  drawing  will  exhibit 
the  manner  of  its  employment. 

It  is,  however,  very  seldom  that  any  of  these  operations  are  ne- 


474  ORAL  DISEASES  AND  SURGERY. 

cessary  for  the  arrestation  of  hemorrhage  about  the  face  or  mouth. 
Cold  water  thi'own  over  the  bleeding  part  from  a  sponge  will  fre- 
quently cause  such  a  contraction,  both  of  vessels  and  tissues,  as  to 
control  it  quickly  enough.  If  water  alone  will  not  answer  the  pur- 
pose, let  alum  be  added,  as  much  as  the  water  will  dissolve.  If  even 
this  should  not  answer  the  end,  use  a  syringe,  throwing  a  jet  from 

Fig.  92. — C^os'^ed  or  Knotted  Bandage. 


a  distance  directly  upon  the  part  bleeding ;  this  last  will  seldom  dis- 
appoint.    Monsel's  solutions,  so  warmly  lauded  for  their  styptic 
qualities,  have  exhibited  to  me  more  ill  results  than  I  have  ever  met 
with  from  any  dozen  other  articles.     If  used  at  all,  I  think  the  | 
bleeding  points  should  be  alone  touched ;  but  of  one  thing  any  one  i 
using  them  may  be  assured :  if  the  application  does  not  control  the  ■ 
hemorrhage  instantly  and  permanently,  he  will  have  increased  his  ! 
trouble  manifold.  ! 

A  hemorrhage  that  is  venous  or  capillary  will  seldom  require  i 
more  than  an  application  of  cold  water.  If  this,  or  the  alum-water, 
should  fail,  astringent  medicines  may  be  administered  internally. 
Of  the  anti-hemorrhagic  medicaments,  none  has  ever  stood  me  in 
better  purpose  than  a  tincture  of  the  Erigeron  Canadense  ;  one  drop 
to  be  given  in  a  teaspoonful  of  water  each  minute.  This  dose  seems 
like  a  very  small  one,  but  a  larger  administration  has  always  appeared 
to  me  to  do  harm  rather  than  good.  Opium  and  lead  I  have  used 
with  much  satisfaction,  one  grain  of  the  former  to  two  of  the  latter; 
three  or  four  of  such  pills  may  be  administered  at  intervals  of  from 
one  to  two  hours  each,  if  found  necessary. 

SHOCK. 

Depression  generally  attends,  to  a  greater  or  less  extent,  the  recep- 
tion of  all  wounds.     Surgeons  divide  shocks  into  primary  and  sec- 


WOUNDS   OF  MOUTH  AND   ASSOCIATE  PARTS.     475 

ondary,  or  that  which  is  immediate  upon  the  reception  of  the  injury, 
and  that  which  does  not  exhibit  itself  until  some  later  period. 
Shock  is  prostration;. this  may  be  simply  of  a  nervous  nature,  im- 
plying functional  disturbance  ;  or  it  may  be  organic,  implying  injury 
of  some  vital  part;  it  may  again  have  the  twofold  relation. 

In  my  own  experience  I  have  found  few  things  more  important  to 
observe  than  the  differences  between  real  and  apparent  shock.  One 
person,  heavy  and  lymphatic  in  temperament,  shall  receive  an  injury 
mortal  in  its  character,  and  yet,  as  the  immediate  or  primary  shock 
is  concerned,  affords  less  evidence  of  such  injury  than  another  of 
nervous  temperament  who  may  suddenly  be  called  to  look  upon  his 
wound.  Mistakes,  in  such  conditions,  have  very  frequently  resulted 
fatally  to  the  persons  most  concerned.  An  article  in  the  valuable 
work*  of  Prof.  H.  H.  Smith,  of  the  University  of  Pennsylvania,  so 
tersely  considers  this  important  matter  that  I  am  sure  no  language 
could  give  it  better  expression. 

"  In  the  normal  or  healthy  condition  of  the  body,"  says  Professor 
Smith,  "  each  function  is  so  well  and  accurately  performed  as  to  pass 
unnoticed  by  an  ordinary  observer.  The  moment  attention  is  called 
by  marked  inconvenience  to  any  one  part,  that  moment  its  healthy 
action  is  changed,  the  duration  of  the  disordered  action  varying 
greatly.  When  only  interrupted  for  a  limited  period,  the  function 
may  be  again  performed  without  any  appreciable  alteration,  but  when 
the  interruption  is  of  some  hours'  duration,  the  preservative  action 
'  of  life  may  be  so  impaired  as  to  result  more  or  less  quickly  in  death. 
\  "  When  any  injury  of  a  part  is  of  sufficient  magnitude  to  produce 
;a  marked  derangement  in  the  function  of  the  local  nerves,  reflex  ac- 
'tion  may  induce  such  a  depression  of  the  general  powers  of  life  as 
'will  result  in  the  state  technically  designated  as  Prostration  or 
i  Collaj)se.  This  depressed  condition  is  especially  noticeable  in  the 
[disturbance  of  the  ganglionic  system  and  its  effects  on  the  circula- 
Itory  apparatus,  and  is  shown  either  immediately  or  some  hours  or 
'even  days  after  the  receipt  of  the  injury.  When  apparent  within  a 
i  short  time  after  the  injury,  the  condition  is  designated  as  Immediate 
ior  Primarij  Shock,  but  when  not  developed  until  several  hours  or 
^days  subsequently,  it  is  known  as  Insidious  or  Secondary  Shock. 
I  In  both  there  is  a  common  feature  of  depression,  the  degree  of  which 
, depends  on  the  violence  and  extent  of  the  injury,  or  the  character 
;and  position  of  the  part  injured. 


Principles  and  Practice  of  Surgery,  by  Henry  H.  Smith,  M.D.,  etc. 


476  ORAL  DISEASES  AND   SURGERY. 

"  In  the  lighter  forms  of  primary  shock  the  patient  trembles,  is 
pale,  faint,  and  with  an  anxious  countenance ;  and  much  the  same 
symptoms  are  said  by  Longmore*  '  to  be  witnessed  in  the  horse, 
mortally  hit,  no  less  than  in  his  rider ;  the  graver  the  injury,  the 
graver  and  more  persistent  is  the  shock.'  In  marked  cases  the 
pulse  is  small  and  feeble  or  fluttering;  the  respiration  somewhat 
oppressed  and  sighing ;  the  skin  pale  and  moist,  with  cold  perspira- 
tion ;  while  nausea,  vomiting,  and  hiccough  are  also  seen,  and  in 
some  cases  there  is  often  well-marked  convulsions.  The  disorder 
of  the  nervous  system  varies  greatly,  and  is  sometimes  rather  the 
result  of  mental  than  of  corporeal  action,  as  in  a  pistol-shot  in  an 
extremity  not  involving  important  parts,  but  in  which  the  patient's 
mind,  having  been  impressed  with  the  danger  to  which  he  was 
exposed,  continues  for  some  time  subsequently  to  influence  his  cor- 
poreal functions.  The  violence  of  the  symptoms  of  primary  shock, 
in  connection  with  moderate  injuries,  will  depend  often  on  the  tem- 
perament of  the  patient,  and  his  mental  condition  at  the  time.  If 
excited  by  passion,  quite  severe  injuries  will  often  pass  unnoticed, 
while  in  cool  blood  the  very  idea  of  a  simple  operation  will  suffice, 
in  some  persons,  to  produce  nervous  prostration  of  a  marked  char- 
acter, so  much  so  as  readily  to  induce  syncope.  In  gunshot  wounds 
of  the  lower  extremities,  and  in  severe  railroad  injuries,  and  exten- 1 
sive  burns,  the  symptoms  of  shock  are  usually  most  marked.  In ' 
these  cases  the  patient  sometimes  loses  his  consciousness  entirely,  i 
and  becomes  faint,  exhibiting  great  mental  disquietude,  with  absence  ; 
of  thought,  and  giving  foolish  answers,  or  incoherent  mutterings. 
The  skin  is  covered  by  a  cold  sweat,  and  is  pale  and  flabby;  the 
muscles  are  all  relaxed;  the  arm,  if  raised,  drops  as  if  paralyzed; 
the  sphincters  of  the  bladder  and  anus  permit  the  escape  of  urine 
and  feces,  and  of  this  the  patient  is  unconscious.  Respiration  is 
much  disordered,  and  barely  perceptible  ;  the  pulse  hardly  to  be  felt; 
the  action  of  the  heart  feeble,  or  sometimes  so  faint  as  only  to  be 
heard  by  applying  the  ear  to  the  chest;  the  eyes  have  a  vacant  ex- 
pression ;  the  eyelids  when  raised  remain  open  from  want  of  action 
in  the  orbicularis  palpebrarum  ;  the  jaw  drops,  and  the  hearing  is 
temporarily  lost,  or  is  stimulated  only  by  loud  noises — the  patient 
remaining  in  this  semi-dead  condition  for  a  period  which  varies 
greatly,  as  from  a  few  minutes  to  hours,  according  to  the  extent  of 
the  shock.     In  the  milder  forms,  with  sufficient  consciousness  re- 

*  On  Gunshot  Wounds,  Phila.  edit.,  p.  45. 


WOUNDS   OF  MOUTH  AXD   ASSOCIATE  PARTS.     477 

maining,  there  is  only  a  mental  commotion,  so  as  to  permit  easy 
reassurance ;  but  in  the  more  marked  degree  this  is  often  difficult 
ieath  sometimes  supervening  without  reaction,  though  most  fre- 
pently  a  certain  amount  of  reaction  is  established  and  conscious- 
less  returns,  or  prostration  again  supervenes  and  the  patient  dies. 
When  a  limb  is  shot  or  torn  away,  or  the  body  badly  scalded,  the 
ocal  paralysis  induced  by  the  injury  apparently  prevents  its  imme- 
iiate  perception  by  the  brain,  and  in  numerous  instances  the  patient 
aas  been  ignorant  of  the  loss  of  a  limb  until  his  attention  was  called 

0  it.  But  as  soon  as  the  brain  becomes  cognizant  of  the  injury, 
md  the  stage  of  depression  or  shock  sets  in,  these  apparently  dis- 
ant  local  injuries  are  attended  by  the  symptoms  just  enumerated, 
hough  they  are  seen  less  quickly  than  when  the  injury  involves  the 
Tunk  or  head.  When  the  symptoms  of  shock  are  marked,  serious 
nternal  injury  may  be  diagnosed  even  though  not  apparent  at  the 
noment.  In  most  cases  of  marked  shock  the  power  of  deglutition 
s  more  or  less  impaired  for  the  time,  while  even  in  the  milder  in- 
stances the  patient  experiences  such  difficulty  in  swallowing  as 
vill  cause,  when  the  attempt  is  made,  the  sudden  spasmodic  effort 
lesignated  as  a  '  gulp,'  or  the  portion  partially  swallowed  is  ejected 
nth  symptoms  of  strangulation,  often  evidently  of  a  hysterical 
.haracter.  When  consciousness  is  not  so  much  impaired  the  patient 
oay  be  able  to  control  the  pharyngeal  muscles,  yet  those  of  the  ex- 
remities  will  be  so  imperfectly  regulated  as  to  cause  the  limbs  to 
iCemble  as  if  with  fright,  or  as  if  exhausted  by  violent  exercise. 

1  "  Duration. — The  duration  of  the  primary  shock  is  very  varied. 
:n  mild  cases  it  disappears  rapidly,  the  patient  quickly  recovering ; 
ihe  depression  or  the  disposition  to  syncope  passing  away  and 
[saving  him  feeble  in  his  circulation  as  well  as  in  his  general 
.trength.  But  in  more  marked  cases,  as  in  the  crushing  of  a  limb 
|y  a  railroad  train,  or  by  machinery,  or  a  round  shot,  the  collapse 
lists  for  several  hours,  when  the  powers  of  life  rallying,  reaction 
Iccurs,  and  there  is  a  renewal  of  the  ordinary  functions  of  the 
lervous  system,  noted  in  the  circulation,  which  now  tends  to  ex- 
jessive  action  as  much  above  the  healthy  standard  as  the  depression 
i^as  below  it. 

i  "  This  reaction  after  the  shock  of  injury,  if  not  regulated  by  ap- 
propriate treatment,  frequently  creates  a  hypersemia  or  congestion 
|f  the  blood-vessels,  and  soon  develops  inflammation  and  traumatic 
i;ver.  To  prevent  this,  and  keep  the  reaction  from  exceeding  its 
[roper  bounds,  and  yet  raise  the  flagging  powers  of  life,  is  the  im- 
[ortant  indication  to  be  accomplished  in  the  treatment. 


478  ORAL   DISEASES  AXD  SUEGERV. 

"Treatment  of  Primary  Shock. — In  mild  cases  of  shock,  a' 
few  encouraging  words,  a  mouthful  of  water,  or  wine  and  water, 
with  judicious  explanations  of  the  limited  extent  of  the  injury,  will 
often  suffice ;  but  in  marked  cases,  when  the  panent's  consciousness 
is  impaired,  and  his  powers  of  deglutition  are  temporarily  paralyzed 
or  much  weakened,  our  means  of  reviving  the  action  of  the  system 
must  at  first  be  limited  to  such  remedies  as  can  be  applied  without 
being  introduced  into  the  mouth.  The  best  plan  of  treatment  is, 
therefore,  to  dash  cold  water  on  the  head  and  face ;  to  excite  arti- 
ficial respiration  by  gently  and  quickly  compressing  the  costal  car- 
tilages, or  by  the  '  Ready  Method '  of  Marshall  Hall ;  by  applying 
stimulating  vapors,  as  strong  ammonia,  to  the  nostrils  ;  by  exciting 
the  nerves  of  the  skin  by  sinapisms  applied  especially  to  the  epigas- 
tric and  cardiac  regions,  and  to  the  extremities ;  by  applying  heat 
to  the  surface  of  the  body  through  hot  bricks,  bottles  of  hot  water, 
etc.,  and  by  rousing  the  dormant  action  of  the  sympathetic  nerves, 
through  the  bowels,  by  administering  stimulating  enemata,  as  oleum 
terebinthinfe,  infusion  of  capsicum,  etc.,  sufficiently  diluted  with 
water  or  mucilage  to  prevent  the  development  of  rectal  inflamma- 
tion. About  5ij  of  ol-  terebinthinae  in  a  pint  of  soap-suds  or  salt 
water  usually  suffices. 

"  When  by  the  continued  use  of  these  remedies  the  patient  regains 
sufficient  consciousness  to  be  able  to  swallow,  or  when  the  depres- 
sion has  not  gone  so  far  as  that  just  alluded  to,  stimulants  may  be 
cautiously  introduced  into  the  stomach.  Of  these,  such  should  be 
selected  as  are  not  likely  to  induce  congestion  of  the  cerebral  ves- 
sels ;  hence  ten  or  fifteen  drops  of  the  aromatic  spirits  of  ammonia 
in  a  little  water,  repeated  every  ten  or  twenty  minutes,  answers 
better  than  alcoholic  liquors,  unless  the  latter  are  given  in  moder- 
ate quantities,  and  their  intoxicating  tendency  carefully  guarded 
against. 

"As  the  pulse  begins  to  respond  to  these  measures,  the  use  of  both 
external  and  internal  stimulants  should  be  omitted,  the  natural  tend- 
ency being  to  a  reaction  that  must  be  restricted  to  proper  limits. 
Should  the  pulse  become  full,  hard,  and  frequent,  so  as  to  indicate 
febrile  reaction,  cold  drinks,  cold  sponging,  saline  cathartics,  and 
arterial  sedatives,  such  as  five  drops  of  the  tincture  of  veratrum 
viride  every  hour,  may  be  necessary — the  powerful  action  of  the 
latter  remedy  requiring  its  cautious  administration,  so  as  to  repress 
but  not  depress  too  much  the  action  of  the  circulation.  The  strong 
tincture  of  aconite  root,  in  doses  of  two  drops,  or  of  tinct.  of  digitalis, 


u 


WO[T.\WS   OF  310 UTH  AND   ASSOCIATE  PARTS.     479 


in  the  dose  of  ten  drops  every  two  hours,  for  a  few  hours,  may  also 
be  advantageously  used,  if  carefully  watched  and  omitted  as  soon  as 
the  force  and  frequency  of  the  pulse  indicate  their  sedative  action. 
By  judicious  attention  to  the  proper  action  of  the  circulation  in  these 
cases,  carefully  stimulating  the  patient  when  in  the  collapsed  or  de- 
pressed condition,  and  inducing  sedation  when  the  reaction  becomes 
excessive,  patients  may  be  rallied  from  the  shock  of  injury  and  subse- 
quently treated  as  demanded  by  the  peculiar  nature  of  the  case.  In 
that  mild  degree  of  shock,  sometimes  seen  in  patients  who  have  been 
shot  by  a  bullet  in  the  extremities,  or  struck  on  the  testicles  or  in  the 
pit  of  the  stomach,  which  is  characterized  by  faintness,  trembling, 
and  mental  anxiety,  a  little  cold  water,  or  wine  and  water,  with  a  few 
words  of  hope  as  to  the  result  of  the  injury,  often  suffices. 

"  In  many  severe  injuries,  and  especially  in  those  which  involve 
the  main  trunks  of  large  nerves,  or  the  spinal  cord,  or  a  great  extent 
of  the  surface  of  the  body,  there  is  sometimes  noted,  at  varying 
periods  after  the  reception  of  the  injury,  a  train  of  symptoms  of  a 
marked  character,  that  are  very  justly  spoken  of  as  those  of  the 
secondary  or  insidious  shock  of  injury. 

"Symjjfoms. —  The  symptoms   of  insidious   shock   are   often   so 

masked   as  to  escape  the  attention  of  an   inexperienced  observer, 

until  they  are  so  far  developed  as  to  render  it  diSicult  to  rally  the 

forces  of  the  j)atient.     Thus  when  a  limb  has  been  torn  off  by  a 

cannon-ball,  or   in  a  rolling-mill,  or  a  thrashing-machine,  or  by  a 

railroad  train,  the  patient  not  unfrequently  appears  to  be  almost 

,  unconscious  of  the  severity  of  his  injury,  the  local  paralysis  being 

'  so  perfect  as  to  prevent  the  excruciating  suffering  that  such  an  injury 

!  would  otherwise  create.    In  the  case  of  the  railroad  accident,  by  the 

collision  of  opposing  trains  on  one  of  our  railroads,  I  saw  a  young 

■  man  who  had  his  arm  cut  off  near  the  shoulder-joint,  with  so  little 

j  suffering  as  to  be  unaware  of  the  extent  of  the  injury  till  his  clothing 

I  was  removed.     By  great  care  he  subsequently  recovered. 

!      "In  numerous  instances  in  the  experience  of  all  surgeons,  such 

;  patients  have  presented  the  following  symptoms  :  immediately  after 

i  the  injury  they  are  remarkably  cool,  self-possessed,  and  as  if  en- 

!  dowed  with  indomitable  fortitude  ;  the  pulse  is  often  barely  acceler- 

,  ated  ;  the  respiration  quiet  and  natural ;  the  skin  pleasantly  warm ; 

\  the  mind  clear,  though  perhaps  a  little  torpid,  but  apparently  with 

i  perfect  consciousness.     In  some  cases  patients  have  been  known  to 

'  walk  or  ride  some  distance,  evidently  unconscious  of  injury,  till  sud- 

;  denly  faintness  supervenes,  and  they  fall  to  the  ground,  and  die  in 


480  ORAL  DISEASES  AND  SURGERY. 

the  course  of  an  hour,  more  or  less.     In  other  cases,  where  the  ex- 
ternal wound  or  injury  is  more  evident,  they  will  give  directions  for 
their  removal,  arrange  their  bed,  business,  etc.;  reply  to  questions 
rationally,  and  with  great  composure ;  yet,  as  has  been  well  described 
by  the  late  Dr.  George  McClellan,*  they  will  present  a  countenance  ! 
that  is  altogether  unnatural,    having  '  an  inquiring,  anxious  look  j 
about  the  forehead,  eyes,  and  upper  portions  of  the  face,  while  all  j 
about  the  mouth  is  smiling  and  composed.'     In  addition  to  which  i 
'they  look  with  a  stare  of  alarm  and  suspicion  at  the  surgeon  when  i 
his  attention  is  called  to  them.'  ! 

"After  this  period  of  treacherous  calmness  has  existed  from  three  j 
to  eighteen  hours,  the  expression  suddenly  changes;  the  lips  be- 
come livid  or  deadly  pale  ;  the  blood  leaves  the  surface  of  the  body; 
the  pulse  flutters  and  becomes  too  rapid  to  count ;  the  respiration  is 
short  and  panting;  a  great  sense  of  oppression  distresses  the  pa- 
tient, and  he  sinks  slowly,  as  if  suffocated,  or  dies  as  if  struck  by 
lightning.  In  these  cases  the  foundations  of  life  are  undermined, 
and  the  paralysis,  which  was  at  first  limited  to  the  part  injured, 
suddenly  extends  to  the  nervous  centers,  and  life  is  arrested  by  the 
want  of  proper  nervous  force. 

"Prognosis. — The  prognosis  in  cases  of  severe  injury,  in  which  i 
the  patient  is  thus  unconscious  of  suffering,  cannot  be  too  guarded,  i 
the  patient  not  being  out  of  danger  from  insidious  shock  until  after  j 
the  lapse  of  forty-eight  hours  of  perfect  tranquillity.  In  the  majority  ; 
of  such  cases,  when  secondary  shock  supervenes,  death  ensues.  i 

"Treatment. —  The  treatment  of  secondary  or  insidious  shock  | 
should  be  chiefly  prophylactic,  special  attention  being  given  to  the  | 
preservation  of  the  powers  of  the  nervous  system  by  the  adminis-  ! 
tration  of  food  and  stimulants,  while  all  muscular  action  on  the  part  ' 
of  the  patient  should  be  carefully  guarded  against.  I 

"  In  many  cases  it  will  be  useful  to  give  milk-punch,  beef-tea,  ! 
quinine,  carbonate  of  ammonia,  chalybeates,  etc.  as  often  as  possi- 
ble, until  some  evidence  is  shown  of  their  effect  upon  the  circula-  i 
tion.  Then,  while  the  patient  is  strictly  confined  to  the  recumbent  i 
position,  stimulating  frictions  should  be  made  along  the  spine,  cold  i 
applied  to  the  head  if  it  becomes  hot,  pediluvia  or  hot  bottles  applied  ' 
to  the  feet  if  cold,  and  access  given  to  a  sufficient  amount  of  fresh  j 
air  in  the  chamber  to  favor  active  respiration,  while  the  patient  is  at  ! 
i 

*  Principles  and  Practice  of  Surgery,  p.  18.  Phila.,  1848.  Edited  by  Dr.  I 
Jno.  H.  B.  McClellan. 


WOU.\WS   OF  310  Um  AND   ASSOCIATE  PARTS.     481 

the  same  time  kept  warmly  covered  up  in  bed.  By  such  means  the 
occurrence  of  secondary  shock  may  be  prevented;  but  should  it 
supervene,  nothing  but  powerful  stimulants  to  the  spine,  or  the  ad- 
ministration of  ether,  brandy,  tincture  of  capsicum,  etc.,  with  the 
free  use  of  beef  essence,  affords  a  hope  of  checking  the  rapid  prostra- 
tion that,  if  not  watched,  will  carry  off  the  patient.  In  every  case 
of  serious  laceration  of  a  limb,  opening  a  large  joint,  tearing  nerves, 
etc.,  cautious  watching  of  the  pulse  can  alone  guard  against  the  de- 
velopment of  insidious  shock.  If  the  patient  is  disposed  to  sleep, 
let  the  pulse  be  noted,  and  let  him  be  awakened  every  hour  to  take 
nourishment,  if  the  pulse  begins  to  flag.  As  the  symptoms  of  shock 
are  usually  the  result  of  serious  and  extended  injury,  the  question 
of  the  propriety  of  operating  for  the  relief  of  the  injured  part  will 
often  arise.  Unless  in  the  case  of  the  laceration  of  blood-vessels 
from  which  the  blood  oozes,  the  opinion  of  most  surgeons  is  adverse 
to  the  propriety  of  operating  until  reaction  is  fully  established ;  and 
since  unconsciousness  can  be  readily  induced  by  the  use  of  anaes- 
thetics, the  supposed  advantages  derivable  from  amputating  a  limb 
while  the  patient  was  unconscious  of  the  injury,  are  generally  re- 
garded as  evidence  of  a  want  of  judgment  on  the  part  of  the  operator. 
How  soon  after  reaction  an  amputation  should  be  performed,  will  de- 
pend on  circumstances,  and  be  again  alluded  to  when  speaking  of 
the  advantages  of  primary  over  secondary  amputations. 

"  Occasionally  it  happens  that  after  reaction  is  established  and 
traumatic  fever  supervenes,  the  patient  becomes  delirious,  or  trau- 
matic delirium  or  wandering,  without  fever,  is  met  with.  If  this 
!  delirium  is  an  attendant  on  the  febrile  condition,  sedatives,  cooling 
;  applications,  and  the  judicious  use  of  opiates,  with  antiphlogistic 
I  remedies,  as  antimony,  arterial  sedatives,  and  such  others  as  are 
adapted  to  inflammatory  fever,  will  be  required;  in  other  cases 
I  opiates  are  mainly  sufficient.  Should  delirium  tremens  supervene, 
I  the  usual  treatment,  as  described  in  treatises  on  the  practice  of  med- 
j  icine,  with  great  attention  to  the  seat  of  injury,  will  be  requisite. 
I  Among  high  livers  or  in  the  intemperate,  a  comparatively  slight 
•  injury  will  often  induce  an  attack  of  delirium  tremens,  requiring 
1  opiates  and  stimulants  to  counteract  it,  or,  if  the  pulse  is  exceed- 
I  ingly  frequent  without  prostration,  the  administration  of  large  doses 
'  of  the  tincture  of  digitalis  or  veratrum  viride.  In  delirium  tremens 
I  supervening  on  pistol  wounds,  in  many  of  our  volunteer  soldiers  in 
j  camp  for  the  first  time  and  deprived  of  their  habitual  drams,  I  have 
>  31 


482  ORAL  DISEASES  AND   SURGERY. 

seen  marked  benefit  derived  from  the  administration  of  half  an  ounce 
of  the  tincture  of  digitalis  every  four  hours  until  three  doses  are 
taken,  this  apparently  heroic  treatment  sometimes  inducing  a  per- 
fect cure  in  thirty-six  hours.  As  the  dose  advised  is  very  large,  the 
pulse  should  be  cautiously  watched  before  it  is  repeated." 

Virus. If  a  rabid  dog,  or  other  animal,  bite  the  part  we  are  con- 
sidering, or  any  part, — if  a  poisonous  serpent  strike  its  fang,  or  even 
if  the  loose  kiss  of  the  chancrous  lip  inoculate, — a  first  indication  is 
to  get  clear  of  the  poison.  How  ?  It  is  now  very  generally  ac- 
cepted that  the  immediate  application  of  solid  nitrate  of  silver  to  the 
parts  wounded  will  neutralize  these  poisons,  or  that,  at  an}^  rate,  it 
will  so  alter  the  condition  of  the  wounded  part  as  to  slough  ofi"  the 
oflFending  agent,  and  prevent  its  absorption.  If  an  escharotic  is  not 
at  hand,  and  this,  at  the  moment,  would  be  not  unlikely,  such  a 
wound  may  be  cut  away.  Suction  is  also  an  admirable  prophylactic 
(not  as  the  chancre  inoculation  is  concerned,  there  would  be  here 
no  immediate  hurry)  for  most  poisonous  introductions.  The  danger 
to  the  person  sucking  such  a  wound  would  be  very  trifling;  any 
danger  at  all  depending  on  a  casual  abrasion  that  might  at  the 
time  be  present  about  the  mouth  or  lips.  Excision  of  bitten  parts 
is  frequently  practiced.  I  recall  an  occasion,  several  years  ago, 
where  an  enraged  rattlesnake  escaped  from  an  experimenter,  strik- 
ing its  fangs  into  a  colored  assistant  standing  by.  Without  a 
moment's  hesitation,  the  gentleman  excised  the  part ;  no  harm  ever 
came  of  the  matter.  Tiding  a  patient  over  the  depression  of  rattle- 
snake poison  by  the  stimulus  and  specific  effects  of  whisky,  has 
received  so  many  confirmations  as  to  have  become  a  matter  of 
common  knowledge.  In  my  own  practice  I  have  had  on  several 
occasions  to  excise  poison  wounds,  and  all  have  been  successful. 
Without  exception,  however,  the  wounds  excised  have  been  received 
through  some  intervening  substance,  and  such  substances  may  have 
prevented  the  introduction  of  any  poison. 

Healing  Wounds. — Primary  indications  met,  the  second  ques- 
tion is  the  healing  of  a  wound.  Every  wound  heals  by  granular 
tion.  The  difference  between  a  healing  by  first  intention  and  a  heal- 
ing by  second  intention  is  only  a  difference  in  degree.  An  incised 
wound,  delicately  and  accurately  approximated,  heals  with  so  little 
new  inter-tissue  that  Mr.  Paget  mentions  cases  where  no  line  of 
difference  was  discernible  even  under  the  microscope.  A  healing  by 
second  intention,  so  called,  may  require  so  many  granules  to  fill  up 
a  gap  that  the  new  or  cicatricial  tissue  is  observable  at  a  great  dis- 


WOUNDS   OF  MOUTH  AND   ASSOCIATE  PARTS     483 

tance,  as  is  frequently  witnessed  in  scars  from  burns.  An  indication, 
then,  of  the  utmost  importance  to  be  met  in  wounds  about  the  facej 
is  the  avoidance  of  a  necessity  for  new  tissue.  To  accomplish  this' 
every  wound  is  to  have  its  parts  as  nearly  approximated  as  possible^ 
and  the  associated  vascularity  modified,  or  at  least  controlled. 

How  wounds  are  best  approximated  is  a  matter  which  is  always 
eliciting  discussion.  The  common  methods  are  by  stitches,  plasters, 
and  compresses.  An  incised  wound,  of  limited"  extent,  about  the 
cheek,  seldom  needs  more  than  that  a  strip  of  adhesive  plaster 
shall  be  thrown  across  it.  If  such  a  wound  occupies  the  position  of 
the  lips,  and  shall  have  made  a  complete  separation,  adhesive  plaster 
will  not,  perhaps,  be  found  sufiBcient  for  the  purpose.  To  insure  the 
least  scar,  a  stitch  may  be  used  to  approximate  the  free  edges,  and 
the  parts  then  forced  and  held  together  by  placing  two  lateral  com- 
presses at  the  sides  of  the  wound,  and  supporting  these  with  a  turn 
of  the  circular  bandage  ;  or  it  may  be  found  that,  after  the  stitch, 
the  adhesive  strips  will  answer  the  purpose.  Pins,  with  a  figure-of-8 
\  turn  about  them,  make  a  very  nice,  reliable,  and  accurate  adaptation, 
;  and,  if  not  kept  in  too  long,  leave  very  little  scar. 

A  mode  of  approximation,  which  will  be  found  very  satisfactory, 
consists  in  using  a  suture  of  silver  wire,  and  bringing  the  edges  of 
I  the  wound  together,  as  directed  in  cleft  palate.     An  objection,  how- 
ever, it  must  be  admitted,  to  all  pins  and  stitches,  lies  in  the  fact  of 
new  wounds  being  made, — an  irritation  being  begotten  by  the  pres- 
ence of  the  foreign  body,  which  is  very  apt  to  provoke  more  or  less 
suppuration,  thus  making  other  scars,  as  is  witnessed  so  frequently 
in  operations  performed  for  hare-lip  ;  therefore  it  may  be  set  forth  as 
the  best  practice,  that  any  means  which  breaks  the  flesh  should  be 
avoided,  if  any  other  may  be  made  to  answer.     Silver  or  lead  wire 
is  preferred  to  the  waxed  silk,  only  from  the  fact  that  these  me- 
I  tallic  agents  seem  to  irritate  less,  and  are,  therefore,  not  so  likely  to 
I  make  points  of  suppuration,  and  consequently  scars. 
j      When  pins  or  stitches  are  used,  they  are  to  be  left  in  place  only  so 
i  long  as  is  absolutely  necessary.     This  time  will,  of  course,  depend 
I  very  much  on  circumstances.     If  an  incised  wound  does  as  well  as 
it  may,  sixty  to  seventy  hours  will  usually  be  found  sufficient  for 
j  the  union,  while  instances  enough  exist  where,  in  this  time,  the  pro- 
,  cess  of  repair  seems  scarcely  to  have  commenced.    A  very  good  way 
I  to  obtain  information  is  to  sponge  off  the  wound,  and  to  be  instructed 
iby  the  line  of  approximation  ;  if  this  continues  to  show  its  incised 
nature,  the  pins  are  not  to  be  disturbed  ;  if,  on  the  contrary,  it  is  a 


484  OBAL  DISEASES  A.\W  SURGERY. 

fleshy  line  of  comparative  solidity,  the  pins  may  be  removed, — the 
parts  will  hold. 

The  withdrawal  of  a  pin  or  ligature  is  a  matter  demanding-  delicacy 
of  manipulation.  It  is  frequently,  and  indeed  generally,  the  case, 
that  more  or  less  blood-rust  collects  upon  a  pin,  making  the  removal 
a  matter  of  such  difficulty  that,  unless  the  precaution  be  taken  to 
scrape  away  such  rust  before  making  the  attempt,  a  disturbance 
of  the  cicatrix  is  almost  inevitable.  In  the  withdrawal  of  a  pin, 
an  important  matter  is  the  rotation  of  it ;  such  rotation  facili- 
tates the  removal  wonderfully.  Metallic  ligatures  are  generally  dis- 
turbing ;  the  proper  plan  to  take  them  away  is  to  cut  the  wire  at 
the  side  of  the  spot  or  knot  opposite  to  that  on  which  it  seems 
desirable  to  withdraw  it ;  the  end  is  then  to  be  carefully  straight- 
ened, so  as  to  place  it  on  a  line  with  the  part  in  the  wound  ;  sup- 
port is  to  be  given  the  cicatrix  by  a  finger  applied  on  either  side, 
when,  with  a  rotatory  movement,  the  wire  is  to  be  drawn  away. 
In  the  use  of  the  pin  and  figure-of-8,  a  very  excellent  plan  is,  on 
the  removal  of  the  pin,  to  allow  the  blood-matted  silk  to  remain 
glued  to  the  wound ;  it  serves  very  much  to  hold  the  parts  together, 
and  is  entirely  void  of  any  offense  as  a  source  of  irritation. 

When  plasters  are  used,  it  is  a  necessity  to  have  all  hairs  shaved 
away  and  the  parts  perfectly  dry.  The  ordinary  adhesive  kept  on 
sale  by  every  druggist,  composed  of  resin  and  lead  plaster,  is  per- 
haps open  to  as  little  objection  as  any.  It  is  to  be  applied  in  strips 
of  convenient  length  and  breadth,  and  rendered  adhesive  by  holding, 
for  a  moment,  the  back  of  the  strip  over  a  vessel  of  hot  water.  There 
are  skins,  however,  which  this  plaster  irritates  and  inflames ;  when 
cases  of  the  kind  are  encountered,  it  is  well  to  employ  the  isinglass 
plaster.  An  objection  to  this  plaster  is  its  tendency  to  curl,  and 
roll  up.  It  is  applied  by  moistening  the  glazed  surface  with 
water. 

In  the  use  of  plasters,  it  is  a  good  rule  to  allow  a  space  between 
each  strip;  this  not  only  keeps  the  wound  exposed  to  observation, 
but  permits  of  easy  drainage.  An  only  exception  to  such  rule  is 
found  in  small  cuts  where  it  is  thought  desirable  to  use  collodion. 
This  mixture  of  gun-cotton  and  ether  is  applied  either  directly 
over  a  cut — first  nicely  approximating  the  edges,  and  holding  the 
parts  together  until  the  ether  has  evaporated — or  indirectly  through 
the  agency  of  saturated  slips  of  gauze  or  other  convenient  ma- 
terial. 

The  removal  of  a  plaster  is  to  be  effected  by  drawing  the  strip 


WOUNDS   OF  MOUTH  AND  ASSOCIATE  PARTS     485 

from  either  side  toward  the  wound;  such  a  removal  beino-  accom- 
plished without  any  strain  upon  the  cicatrix,  the  line  of  union  beinir 
of  course,  supported  by  the  thumb  and  forefinger  of  the  other  hand. 
If  a  wound  seems  to  be  doing  well  under  plaster,  there  need  be  no 
special  haste  in  its  removal.  It  is  usually  the  case,  however,  that 
such  a  dressing  will  not  continue  to  do  service  longer  than  two  or 
three  days.  In  simple  incised  injuries,  this  is  generally  all  that  is 
required,  but  in  lacerated  wounds,  dressings  are  demanded  an  in- 
definite length  of  time,  and  require  continued  renewal.  In  reapply- 
ing a  dressing  of  adhesive  strips,  a  good  plan  is  to  displace  and 
replace  one  at  a  time. 

Complicated  Wounds. — The  history  of  a  few  cases  may,  per- 
haps, best  serve  to  illustrate  practice  in  this  direction. 

Case  I. — Little  girl,  of  remarkably  perfect  temperament,  about 
four  years  of  age,  brought  into  the  office  with  quite  a  gash  in  the 
lower  lip,  and  the  six  anterior  teeth  knocked  directly  back ;  consider- 
able hemorrhage. 

Treatment. — Checked  the  hemorrhage,  and  cleaned  the  parts  by 
the  free  use  of  cold  water  applied  through  the  syringe ;  pushed 
the  teeth  back  into  their  unfractured  alveoli,  and  retained  them  in 
place  by  laying  a  delicate  roller  over  them,  fixing  it  beneath  the 
chin.  A  single  stitch  of  waxed  silk  was  placed  in  the  wound  of 
the  lip.  The  case  was  dismissed  for  the  day,  with  directions  to 
keep  the  parts  refrigerated  through  a  continuous  application  of  cold 
water. 

Second  day.  Same  treatment  continued,  the  band  over  the  teeth 
being  replaced  by  a  fresh  one. 

Third  day.  Wound  in  the  lip  healed  sufficiently  to  remove  the 
ligature.  Teeth  somewhat  tightened ;  very  little  inflammation  ; 
continued  the  bandage,  but  left  off  the  application  of  the  water. 

Fourth  day.  Removed  the  bandage.  Teeth  very  sore,  but  doing 
well,  and  quite  fast. 

Eighth  day.  Patient  dismissed ;  some  soreness  still  in  the  teeth, 
but  needing  only  time  to  bring  them  to  full  health. 

This  case  was  seen  three  months  after  the  accident— there  was 
no  discoloration  of  the  teeth,  and  not  the  slightest  evidence  that 
any  harm  had  been  done  them. 

Case  II.— Child  six  years  of  age.  Four  front  inferior  teeth 
knocked  loose  by  a  blow  from  a  ball ;  some  contusion  of  the  lip, 
but  no  break  in  the  continuity  ;  very  little  bleeding. 

Treatment.— VxemoYeOi  the  injured  teeth  ;  absorption  having  pro- 


486  ORAL  DISEASES  AND  SURGERY. 

gressed  to   a  considerable   extent,  applied  to  the  lips  dressing  of 
cold  water ;  case  well  enough  to  dismiss  next  day. 

Case  III. — Little  boy,  five  years  of  age,  fell  upon  a  curbstone, 
fracturing  the  superior  alveolar  process.  Examination  revealed  six 
teeth  movable  in  mass,  the  fracture  extending  from  tuberosity  of 
right  side  to  canine  fossa  of  left.  The  accident  occurred  nine  hours 
before  recourse  to  treatment. 

Condition. — Child  feverish  and  restless ;  pulse  much  excited ; 
soft  parts  about  the  seat  of  fracture  considerably  swollen,  and  so 
tender  as  to  cause  the  little  patient  to  scream  when  the  parts  were 
touched. 

Treatment. — A  Seidlitz  powder ;  hot  pediluvia ;  the  mouth  sy- 
ringed with  cold  water;  iced  lemonade,  ad  lib.;  spts.  Mindereri,  5ii, 
y'g  gr.  acetate  of  morphia.  This  was  the  treatment  on  the  after- 
noon and  night  of  accident. 

Second  day.  Hot  pediluvia ;  iced  lemonade,  made  of  crushed 
ice  ;  mustard  poultice  at  back  of  neck. 

Third  day.  Swelling  of  gums  very  much  abated.  Fed  the  child 
freely  with  spoon  food,  then  brought  the  fractured  part  to  its  place 
by  reducing  to  proper  articulation  with  lower  teeth,  and  retaining  in 
position  by  means  of  the  yard  strip  modification  of  the  Bai'ton 
bandage — a  fairly  comfortable  day  was  passed.  In  the  evening  the 
bandage  was  loosened,  the  child  again  fed,  the  bandage  tightened, 
patient  put  to  bed — a  comfortable  night  was  passed. 

Fourth  day.  Doing  very  well.  On  loosening  the  bandage  there 
was  very  little  tendency  in  the  fractured  part  to  move  of  itself;  child 
fed  with  soup  food ;  mouth  well  syringed  with  cold  water  ;  bandage 
reapplied.  Patient  played  about  the  room  most  of  the  day,  taking 
lemonade  and  rice-gruel  very  frequently,  by  placing  the  fluid  within 
the  lips  and  sucking  it  between  the  teeth. 

From  fifth  to  tenth  day  did  little  more  than  continue  the  treat- 
ment of  the  fourth. 

Eleventh  day.  Removed  the  bandage.  Fracture  fairly  solid  ;  able 
to  hold  of  itself;  liquid  food  continued;  no  other  treatment. 

Fifteenth  day.  Patient  began  to  eat  solid  food  ;  passing  on,  with- 
out further  treatment,  to  a  good  cure. 

Case  IV. — Little  girl,  three  years  of  age,  markedly  scrofulous  ; 
lip  cut  through;  fracture  of  process  of  central,  lateral  incisor,  and 
cuspid  teeth  of  left  side  inferior  maxilla;  cutting  edges  of  teeth 
thrown  backward. 

Treatment. — The  wound  in  the  lip  being  quite  extensive,  a  hare- 


WOUNDS   OF  MOUTH  AND   ASSOCIATE  PARTS.     487 

lip  pin  was  inserted,  and  the  parts  pushed  together  and  held  with  a 
figure-of-8.  The  fractured  process  was  restored  to  position,  and 
retained  by  tying  the  one  end  of  a  strand  of  waxed  floss  silk  around 
the  last  molar  tooth  of  the  injured  side,  bringing  it  forward,  passing- 
it  between  the  first  molar  and  cuspid  of  the  fractured  part,  back  of  the 
three  teeth  of  the  broken  process,  then^out  between  the  central  in- 
cisors, and  back  to  the  first  molar,  where  it  was  tied.  This  ligature 
supported  the  part  in  its  place  very  well.  The  ferrated  elixir  of 
bark,  in  doses  of  twenty-five  drops,  directed  three  times  a  day. 

Second  day.  Wound  in  the  lip  doing  tolerably  well;  seat  of  frac- 
ture looking  puffy,  and  asthenic.  Very  weak  solution  of  compound 
tincture  of  capsicum  ordered  to  be  thrown,  ter  die,  over  the  part. 

Third  day.  Looking  worse ;  ligatures  cutting  into  the  gums  ; 
patient  refusing  solid  or  soft  food  ;  took  away  the  ligature  ;  tempted 
the  appetite  with  ice-cream  and  jellies ;  scarified  the  puffy  gum. 

Fourth  day.  Matter  oozing  from  about  seat  of  fracture  ;  etherized 
the  child  ;  dissected  down  to  the  fractured  piece,  and  removed  it. 

Sixth  day.  Yery  much  improved;  wound  healing  fairly;  con- 
tinued to  syringe  with  the  dilute  capsicum  comp. 

Eighth  day.  Case  well  enough  to  be  dismissed.  The  pin  in  the  lip 
had  been  removed  on  the  third  day.  The  wound  gaped  some  little; 
but  the  removal  was  a  necessity,  on  account  of  irritation  produced 
by  its  presence;  support  was  giv^en  by  an  adhesive  strip,  after  the 
taking  away  of  the  pin,  and  the  part  stimulated  with  capsicum, 
under  which  it  healed  very  rapidly. 

Case  Y. — M.  L.,  an  iceman,  aged  perhaps  thirty-five,  brought  into 
the  office  immediately  after  having  been  kicked  on  the  mouth  by  a 
vicious  mule.  Patient  very  pale  and  faint.  Examination  revealed 
comminuted  fractures  of  the  alveolar  process  of  both  jaws,  with  the 
teeth  knocked  into  every  position. 

Treatment. — First,  stimulation  with  a  little  brandy.  The  patient 
revived.  Incisions  on  either  side  of  the  teeth  were  made  down  to 
the  bone,  and  some  eight  pieces  removed,  with  the  teeth  associated. 
No  hemorrhage  of  consequence  attended  the  operation,  and  in  the 
course  of  three  or  four  days  the  man  was  going  about  his  business, 
—no  treatment,  outside  of  the  free  use  of  cold  water,  having  been 
indicated  or  employed. 

Case  YI— C.  H.,  struck  over  the  angle  of  the  jaw  l)y  a  Minie- 
ball,  which  plowed  across  the  face,  completely  dividing  the  cheek, 
and  grooving  the  right  nasal  ala.  A  first  treatment  employed  on 
the  field,  where  the  injury  was  received,  consisted  in  associating  the 


488  ORAL  DISEASES  AND  SURGERY. 

severed  parts  with  a  series  of  interrupted  sutures,  and  the  application 
of  a  poorly  adapted  bandage.  In  this  condition  the  patient  was  sent 
several  days'  journey,  to  a  hospital  in  which  I  happened  at  the  time 
to  be  employed.  My  first  observation  of  the  case  exhibited  an  im- 
mense wound,  stiches  all  torn  out ;  superior  maxillary  bone  exposed, 
with  groove  cut  into  it ;  suppuration  most  profuse ;  patient  ex- 
hausted, irritable,  and  feverish. 

Treatment. — The  weather  being  oppressively  hot,  a  large  basin  of 
water  was  brought,  in  which  the  head  and  face  were  thoroughly,  yet 
tenderly,  washed.  The  matted  hair  was  combed  out  and  arranged. 
This  refreshed  him  very  much.  Examination  of  the  wound  was 
commenced.  On  the  groove  in  the  bone  was  found  no  splinter,  nor 
other  indication  adverse  to  the  direct  and  immediate  overlying  of 
It  by  the  soft  parts.  Attention  to  the  line  of  wound  in  the  soft  part 
exhibited  that  the  slough,  which  must  necessarily  have  ensued  from 
the  passage  of  the  ball,  had  completed  itself,  and  that  a  process  of 
repair  was  attempting  to  inaugurate  itself.  Indications  thus  being 
rendered  very  plain,  the  whole  of  the  cut  and  suppurating  surface 
was  slightly  stimulated  by  an  application  of  dilute  tincture  of  iodine, 
and  then  carefully  moulded  into  place  and  approximated.  The  main- 
tenance of  this  apposition  was  accomplished  by  fitting  a  compress  to 
the  cheek,  and  also  below  the  wound,  and  with  a  bandage  carefully 
lifting  and  supporting  it ;  no  stetchers,  pins,  or  plasters  being  em- 
ployed. The  success  was  perfect,  the  whole  line  of  the  wound  being 
exposed,  permitting  the  fullest  and  most  frequent  examination.  In 
ten  weeks  the  parts  had  united  so  firmly  as  to  allow  of  the  removal 
of  the  compress  and  bandage.  The  only  medication  employed  con- 
sisted in  the  administration  of  an  occasional  Seidlitz  powder,  and  a 
daily  glass  of  porter,  with  repeated  applications  to  the  wound  of  the 
dilute  iodine,  one  part  of  the  officinal  tincture  to  four  parts  water. 

Case  VII. — Little  girl  fell  over  the  shafts  of  a  wagon,  cutting  her 
tongue,  in  some  unappreciated  way,  directly  in  twain,  for  the  dis- 
tance of  an  inch  down  the  middle.  Hemorrhage  very  profuse,  re- 
quiring the  ligature  of  a  vessel.  This  wound  was  united  by  two 
stitches  of  the  interi'upted  suture  passed  deep  in  the  substance  of 
the  organ  ;  cold  water  directed  to  be  held,  quite  continuously,  for  the 
first  day  in  the  mouth  ;  patient  fed  on  ice-cream  and  jelly.  Third  day, 
stitches  removed,  union  complete,  ligature  loosened,  and  was  pulled 
away  on  the  seventh  day. 

Case  Till. — Brigadier  General  D.,  standing  upon  an  outlook,  was 
struck  by  a  sharpshooter,  the  ball  passing  through  the  right  ramus 


WOUNDS   OF  MOUTH  AND  ASSOCIATE  PARTS. 


489 


of  the  lower  jaw,  shattering  the  bone,  passing  forward  across  and 
through  the  tongue,  emerging  from  and  splintering  the  body  of  the 
bone  on  the  left  side.  The  treatment  pursued  upon  the  field  had 
been  to  check  an  alarming  hemorrhage  from  the  region  of  entrance 
of  the  ball,  by  stuffing  the  wound  with  charpie  saturated  with 
Monsel's  solution  of  iron,  throwing  a  baiidage  over  it,  and  hurrying 
the  patient  to  the  hospital. 

Condition  on  entrance. — Patient  arrived,  and  was  put  under  my 
care  about  eleven  o'clock  at  night;  complained,  by  writing  on  a 
slate,  of  great  thirst,  with  entire  inability  to  swallow,  and  of  the  pain- 
ful effort  it  required  to  breathe;  had  not  been  able  to  drink  since  the 
accident,  which  happened  two  days  before. 

Treatment. — Examination  revealed  marked  displacement  of  the 
middle  piece  of  the  fractured  bone.  This,  with  the  tongue,  being 
pulled  backward  by  the  hyoid  attachment  of  the  genio-hyoglossal 
muscles,  sufficed  to  explain  part  of  the  difficulty  in  respiration  and 
deglutition.  The  tongue  itself,  however,  was  much  swollen,  and  had 
a  ball  wound  through  its  base.  Two  primary  indications  thus  pre- 
sented: to  keep  the  body  of  the  bone  and  tongue  in  position,  and  to  re- 
duce the  swelling  in  the  tongue.  The  external  wounds  were  for  second- 
ary consideration — the  patient  had  to  breathe  and  had  to  be  nourished. 
The  mouth  was  first  well  syringed  with  cold  water,  which  was  most 
refreshing  to  the  patient ;  the  bone  was  then  brought  forward,  the 
inferior  teeth  in  front  of  the  superior ;  the  jaws  were  closed,  and 
held  together  by  a  delicate  bandage,  the  middle  fragment  being  thus 
retained  even  in  front  of  its  natural  position,  and  pulling  the  tongue 
forward  with  it.  This  accomplished,  the  patient  was  propped  up  in 
an  arm-chair,  and  his  feet  immersed  in  hot  water,  the  application 
being  continued  until  every  vein  and  capillary  was  engorged.  A 
local  abstraction  of  blood  was  not  thought  desirable,  as  he  had 
already  lost  as  much  as  he  could  well  spare.  The  result  of  such  a 
primary  treatment  was,  that  in  half  an  hour  the  patient  was  able  to 
swallow  spoonfuls  of  lemonade.  This  drink,  cold  as  it  could  be 
made,  was  continued  during  most  of  the  night,  serving,  by  its  re- 
freshment, to  give  much  comfort,  and  by  its  refrigeration  to  abate 
the  vascular  excitement.  About  four  o'clock  in  the  morning  the 
patient  fell  into  a  disturbed  sleep,  which  continued  until  eight.  At 
nine  o'clock  the  tongue  was  examined  by  separating  the  lips,  and 
looking  at  it  through  spaces  which  existed  between  the  teeth  ;  the 
swelling  and  turgidity  had  very  much  diminished.  The  feet  were 
again  placed  in  hot  water,  and  the  blood  held  in  the  parts  until  a 


490  ORAL  DISEASES  AND  SURGERY, 

sense  of  faintness  was  experienced.  This  gave  increased  relief.  The 
patient  thus  being  over  the  immediate  danger,  attention  was  di- 
rected to  the  state  of  the  external  injuries,  and  the  line  of  passage 
of  the  ball. 

The  wound  at  the  external  angle  of  the  jaw  was  found  to  occupy- 
quite  a  space  in  the  parotid  fossa,  the  ball  having  been  received 
evidently  as  the  general  had  turned  his  head  to  address  some  one 
behind  him.  It  was  stuffed  with  charpie,  looking  now  a  black  and 
blood-infiltrated  mass,  and  which  evidently  had  been  thrust  hard  and 
solidly  into  the  wound,  and  now  had  swelled  to  double  its  former 
size,  displacing  the  parts  to  a  very  marked  extent.  This  plug  being 
firmly  fixed,  it  was  left  to  be  removed  or  not,  as  circumstances 
should  seem  to  direct,  at  a  future  time.  The  wound  of  exit  was 
larger  than  might  have  been  expected,  spicula  of  bone  having  con- 
siderably torn  the  parts ;  from  this  was  removed  several  small 
splinters.  The  probe,  passed  into  this  opening,  revealed  the  line 
of  the  wound,  running  through  the  base  of  the  tongue  obliquely 
across  the  mouth.  An  only  treatment  consisted  in  the  free  use  of 
permanganate  of  potash  and  water.  The  patient  passed  the  day  in 
a  fair  degree  of  comfort. 

A  sudden  secondary  hemorrhage  being  the  next  thing  to  fear,  it 
was  determined  on  the  third  day  to  remove  the  plug  ;  this  was  ac- 
complished only  after  a  full  hour  of  labor,  the  charpie  having  wedged 
itself  into  every  imaginable  space,  the  removal  being  effected  by 
the  very  free  use  of  milk-warm  water  and  the  most  gentle  of  trac- 
tion with  the  forceps  and  scalpel  handle.  The  removal  was  attended 
with  considerable  pain,  but  without  the  loss  of  a  single  drop  of 
blood ;  the  relief  from  the  sense  of  pressure  afforded  was  so  very 
great  as  to  change  the  whole  appearance  of  the  patient,  he  now 
breathing  and  taking  his  beef  essence  with  the  greatest  freedom. 
The  appearance  of  the  wound  was  really  very  promising,  attempts 
at  granulation  being  quite  evident,  while  nothing  especially  threat- 
ening was  to  be  observed.  The  day  after  this  dressing,  the  patient, 
in  opposition  to  all  advice  or  commands,  insisted  on  being  passed 
to  his  family  in  Washington.  All  the  dangers  of  secondary  hemor- 
rhage were  exposed  and  explained  to  him,  but  he  seemed  to  be  pos- 
sessed of  the  single  idea  of  getting  to  his  home.  At  five  o'clock  in 
the  afternoon  he  was  driven  to  the  steamer  plying  between  Fortress 
Monroe  and  Baltimore,  continued  in  charge  of  a  surgeon  who  had 
been  sent  with  him  from  the  field.  At  midnight,  while  on  the 
Chesapeake,  the  most  profuse  secondary  hemorrhage  came  on,  which 


WOUNDS   OF  MOUTH  AND  ASSOCIATE  PARTS.     491 

was  controlled,  as  best  it  might  be,  by  masses  of  ice  held  continu- 
ously to  the  wound.  The  patient  died  during  the  next  day  at  a 
hospital  on  the  wharf  in  Baltimore — under  what  exact  circumstances 
I  could  not  learn ;  most  likely,  however,  from  exhaustion. 

Case  IX. — J.  B.,  middle-aged  man,  gash,  from  a  blow,  lacerating 
the  cheek,  opening  the  duct  of  Steno. 

Treatment. — With  a  heavy-eyed  needle,  carried  a  loop  from  the 
bottom  of  the  wound  to  the  inside  of  the  cheek — the  silk,  which 
was  very  loose,  conducted  the  saliva  into  the  mouth.  Brought  the 
external  wound  together  by  strips  of  resin  plaster;  no  other  treat- 
ment required,  save  an  occasional  dressing.  In  a  week  the  loop 
had  sloughed  through  into  the  mouth,  preserving  completely  the 
track  for  the  secretion,  and  the  process  of  granulation  had  ad- 
vanced almost  to  the  stage  of  cure  in  the  external  wound;  uo  after- 
trouble. 

Case  X. — C.  A.,  young  gentleman,  twenty  years  of  age,  deep 
punctured  cut  in  the  floor  of  the  mouth  just  to  left  of  middle  line, 
made  by  the  slipping  of  an  elevator  in  the  attempt  to  remove  root 
of  upper  canine  tooth.  Xo  hemorrhage,  or  immediate  bad  sign  of  any 
kind ;  patient  very  much  frightened.  Accident  had  occurred  two 
days  before  my  seeing  the  case ;  part  very  sore  and  tender ;  inflam- 
mation limited. 

Treatment. — Directed  arnica  water  for  relief  of  the  soreness ; 
nothing  else  indicated  or  required ;  the  wound  healing  rapidly  and 
kindly. 

Case  XI. — Cut  received  by  young  lady,  exposing  and  incising 
mylo-hyoid  artery  of  left  side  in  the  groove ;  hemorrhage  very  great 
and  persistent. 

Treatment.— V^u^hi  position  ;  tiuct.  Erigeron  as  directed;  strong 
alum  solution  held  to  the  part  on  tufts  of  cotton,  afterward  thrown 
with  the  syringe ;  ice  to  the  part,  etc.  No  result  on  the  bleeding. 
The  patient  becoming  affected  from  loss  of  blood,  enlarged  the 
wound,  picked  out  the  vessel  with  the  Liston  forceps,  and  tied  it. 
This,  of  course,  controlled  the  hemorrhage.     Patient  recovered. 

Case  XII.— Mr.  C.  Performed  operation  on  the  cheek  for  erectile 
growth  ;  cut  well  into  the  sub-tissue,  making  quite  a  deep  wound, 
just  as  if  the  part  had  been  scooped  out. 

Trea^me?i<.— Cold-water  dressing;  waiting  on  nature  to  fill  up 
wound  with  granulations  ;  nothing  else  required,  nothing  done  ;  the 
case  progressed  to  a  satisfactory  cure,  excepting  a  raised  scar. 

Case  XIII— Young  man,  shot  through  the  cheek;  the  mouth 


492  ORAL   DISEASES  AND   SURGERY. 

beiug,  at  the  time,  fortunately  open,  the  ball  passed  out,  doing  no 
further  damage  ;  no  hemorrhage. 

Treatment. — Applied  cloths  wrung  out  of  cold  water,  for  the  pur- 
pose of  controlling  vascular  reaction;  nothing  else  done;  wound 
suppurated  until  the  compressed  and  devitalized  tissues  were 
sloughed ;  then  kindly  granulated,  the  patient  being  entirely  well 
in  a  month. 

Case  XIV. — Patient,  young  lady.  In  an  attempt  to  extract  the 
jBrst  molar  tooth  of  right  upper  jaw  a  flap  of  gum  had  been  torn, 
extending  around  the  mouth  to  the  left  second  bicuspid  ;  this  flap 
had  been  hanging  loose  some  three  hours  before  the  patient  pre- 
sented herself. 

Treatment. — Cut  it  off,  and  depended  on  granulations  from  the 
wounded  surface  for  the  filling  up ;  patient  comfortable  next  day  ; 
entirely  w^ell  in  a  week ;  no  other  treatment  of  any  kind  required. 

Case  XY. — Boy,  tAvelve  years  of  age ;  playing  with  powder  con- 
tained in  a  bottle,  it  unfortunately  exploded,  throwing  the  glass  and 
powder  into  his  face.  When  first  seen,  an  hour  after  the  accident, 
the  patient  was  in  the  greatest  distress ;  the  eyes  were  completely 
closed,  lashes  entirely  destroyed,  hair  singed,  face  raw  and  bleeding, 
pulse  rapid,  and  very  irritable. 

Treatment. — First,  Seidlitz  pow^der,  with  half  grain  of  opium; 
second,  removal  of  such  pieces  of  glass  as  could  be  readily  picked 
away  with  the  forceps ;  third,  cold-water  dressing.  In  an  hour 
the  patient  was  fairly  comfortable  ;  at  the  end  of  which  time  a  second 
half  grain  of  opium  was  administered. 

Second  day.  Face  very  sore,  but  no  burning  pain  ;  picked  away 
several  small  pieces  of  glass  and  a  number  of  powder  grains.  Con- 
tinued cold-water  dressing. 

Third  day.  Reactive  inflammation  evidently  aborted ;  water 
dressings  dispensed  with  ;  used  in  place 

B.— 01.  lin. 

Aqua  calcis,  aa  q.  s. 

With  this  the  surface  was  protected  from  the  atmosphere  until  it 
cicatrized — a  period  of  two  weeks.  During  the  time  of  cure  some 
little  attention  was  given  to  the  diet,  the  patient  for  the  first  day 
craving  principally  ice-cream,  which  answered  very  well,  and  served 
to  allay  a  slight  tendency  to  irritative  fever  which  existed — the 
latter  four  days  of  the  first  week  stimulating  articles  of  food  were 
interdicted ;  after  this  he  ate  what  he  best  liked. 


WOUNDS   OF  MOUTH  AXD   ASSOCIATE  PARTS     493 

Case  XVI.— Patient,  young  gentleman.  Struck,  while  on  a 
gunning  excursion,  hj  a  buckshot,  which  passed  through  the  lower 
lip,  burying  itself  in  the  bone.  Patient  not  seen  until  the  next  day; 
lip  too  much  swollen  to  perrtiit  of  examination. 

Treatment. — Cold-water  dressing  to  the  lip.  Mag.  sulph.  §ss 
internally. 

TJiird  day.  No  diminution  in  sw^elling ;  slight  erysipelatous 
blush ;  brushed  the  parts  with  the  following  combination : 

R. — Tinct.  ferri  chl.  Jss  ; 
Quinia  sulph.  gr.  xxx  ; 
Tinct.  cinch,  gtt.  x; 
Aqua,  giv.     M. 

In  one  hour  the  blush  disappeared — water  reapplied. 

Fourth  day.  Inflammation,  with  the  swelling,  disappearing  very 
rapidly ;  water-dressing  continued. 

Sixth  day.  Probed  the  wound  ;  discovered  the  shot  lying  near  the 
root  of  the  first  bicuspid  tooth ;  dissected  away  the  gum  from  the 
inside,  and  with  a  very  small  curved  gouge  picked  the  lead  away. 

Seventh  day.  Inflammation  back  again,  confined,  however,  rather 
to  the  inside  of  the  mouth  ;  reapplied  the  cold-water  dressing,  and 
directed  a  Seidlitz  powder. 

Eighth  day.  Better;  inflammation  rapidly  yielding ;  a  little  pus 
escaping  from  the  shot  track  in  the  bone. 

Tenth  to  thirteenth  day.  Track  of  wound  in  the  I)one  suppura- 
ting considerably  ;  tinct.  iodine  injected. 

Foiu'teenth  day.  Discharge  diminishing;  iodine  still  continued. 

Sixteenth  day.  Discharge  entirely  ceased ;  patient  dismissed. 

Case  XYII. — Patrick  T.,  laborer.  While  engaged  in  blasting 
rocks  the  patient  was  struck  with  great  force,  just  below  the  orbit, 
by  a  flying  fragment,  lacerating,  in  a  frightful  manner,  the  soft  parts 
of  the  face,  breaking  and  knocking  into  the  nares  the  left  nasal  bone, 
and  severely  concussing  the  maxillary.  No  hemorrhage;  heavy 
shock. 

Treatment.— T\iQ  patient  being  a  strong,  plethoric  man,  reaction 
was  allowed  to  establish  itself,  and  which  it  did  completely  only 
after  the  lapse  of  several  hours.  Cold-water  dressings  were,  how- 
ever, at  once  applied  to  the  parts,  every  deduction  being  in  favor  of 
the  inference  of  severe  inflammation.  The  accident  occurred  in  the 
morning.  At  seven  in  the  evening,  a  pine  stick,  whittled,  to  make 
its  introduction  easy,  was  coated  over  the  end  by  dipping  it  in 


494  ORAL  DISEASES  AND  SURGERY. 

melted  wax,  and  with  this,  insinuated  into  the  nostril  beneath  the 
depressed  nasal  bone,  it  was  thrust  out  into  place,  position  being 
maintained  by  a  tuft  of  wax-coated  cotton,  having  attached  to  it  a 
string  for  its  withdrawal,  being  pushed  up  beneath  the  fracture. 

Examination  of  the  injured  face  and  maxillary  bone  revealed  con- 
tusion and  injury  to  such  an  extent  as  to  make  it  plainly  evident 
that  the  process  of  cure  must  be  that  of  exfoliation,  sloughing,  and 
repair  by  granulation ;  the  only  treatment  was  then  the  expectant, 
and  this  was  met  by  a  simple  water-dressing. 

Second  day.  Most  decided  reaction.  Mag.  sulph.  ^ss  adminis- 
tered in  half  a  glass  of  water;  water-dressing,  medicated  with  lead 
and  laudanum. 

B. — Plumbi  acet.  5'j  I 
Tinct.  opii,  §ij ; 
Aqua,  3XXX.     M. 

Cloths  wet  with  this  lotion  kept  constantly  upon  the  cheek. 

Third  day.  Inflammation  abating,  but  patient  complaining  of 
feeling  hot  and  generally  miserable.  Lemonade  ordered  as  a  febri- 
fuge, to  be  made  by  expressing  the  juice  of  an  ordinary  lemon  into 
a  goblet,  sweetening,  and  filling  up  the  glass  with  ice  broken  into  a 
coarse  powder.     To  be  allowed  ad  libitum. 

Fifth  day.  Wound  suppurating ;  fever  all  gone  ;  dressing  changed 
to  simple  water  ;  waxed  cotton  changed  in  nostril, — the  replacement 
giving  much  pain. 

From  fifth  to  tenth  day.  Water-dressing  continued ;  portion  of 
external  plate  of  the  bone  apparently  dying ;  periosteum  evidently 
destroyed. 

Eleventh  day.  Stimulation  commenced  ;  parts  wet  three  or  four 
times  a  day  with  the  following : 

R. — Alum  pulv.  5ij  ; 

Tinct.  capsicum  comp.  ^ss  ; 
Aqua,  ^xvi.     M. 

Fifteenth  day.  Granulations  being  thrown  out  from  around  the 
edges  of  the  wound ;  parts  brought  as  closely  together  as  possible, 
and  retained  with  adhesive  strips ;  nasal  fracture  doing  very  well. 

Tvcentyfifth  day.  Wound  of  face  entirely  healed,  with  the  ex- 
ception of  a  small  place  in  the  center,  which,  when  examined  with 
the  probe,  discovered  a  sinus  leading  to  diseased  bone. 

Thirtyfourth  day  Piece  of  bone  presenting  at  the  sinus;  en- 
larged the  opening,  and  withdrew  a  sequestrum  rather  larger  than  an 


WOUNDS   OF  MOUTH  AND  ASSOCIATE  PARTS.    495 

ordinary  finger-nail.  Examination  with  the  probe,  after  the  removal, 
gave  the  fleshy  feel  indicative  of  repair.  Case  dismissed  on  the 
thirty-sixth  day. 

Case  XVIII.— Young  man,  struck  on  the  side  of  the  face,  in  a 
street  brawl,  with  a  slung-shot;  face  severely  cut  and  contused; 
outer  boundary  of  the  antrum  driven  backward  into  the  cavity,  not 
fractured  apparently,  but  simply  bent  inward. 

Treatment. — Cold-water  dressing, — no  other  application  for  the 
first  three  days.  After  this,  the  patient  being  compelled  to  go  out 
to  his  work,  adhesive  strips  were  employed  ;  repair  progressed 
rapidly,  without  a  single  adverse  manifestation.  The  depressed 
plate  of  the  sinus  gave  no  trouble,  soon  accommodating  itself  to  its 
new  position ;  all  sense  of  soreness  leaving  it  by  the  end  of  the 
second  week.     External  wound  cicatrized  in  twenty  days. 

Case  XIX. — A  young  man  slipped  while  standing  on  a  stall  in  a 
market-house  ;  falling  forward  and  downward  upon  one  of  the  hooks, 
it  entered  his  mouth,  breaking  off  three  of  his  upper  teeth,  perfo- 
rated his  hard  palate,  and  passed  by  its  point  into  the  right  nostril. 

Treatment. — Seen  first  one  hour  after  the  accident.  Pain  in  the 
broken  teeth  unbearably  severe.  Examination  discovered  the  en- 
gorged pulps  entirely  uncapped  and  bulging  from  their  cavities. 
The  probe  introduced  through  the  wound  in  the  palate  passed  readily 
into  the  nares,  giving  little  or  no  pain.  No  fracture  of  the  bone, 
save  a  few  trifling  spiculse  about  the  circumference  of  the  puncture. 
The  roots  of  the  broken  teeth  were  at  once  extracted,  and  the  case, 
for  the  time,  left  to  nature. 

Second  day.  No  necessity  for  any  interference ;  some  soreness, 
but  no  actual  pain. 

Third  day.  Nothing  required  to  be  done. 

Fourth  day.  Three  trifling  pieces  of  bone  discharged  into  the 
mouth. 

Seventh  day.  Wound  granulating  very  satisfactorily. 

Fifteenth  day.  Nature  unable,  evidently,  to  quite  fill  up  the  open- 
ing; assisted  by  scarifying  the  circumference  of  the  wound,  and 
touching  with  tincture  of  iodine. 

Seventeenth,  twentieth,  and  twenty-second  days.  Scarified,  and 
touched  with  iodine. 

Twenty-fourth  day.    Opening  completely  closed.    Case  dismissed. 

Case  XX.— Gentleman.  While  striking  the  iron  handle  of  a  chisel 
in  the  act  of  opening  a  box,  a  small  piece  flew  off  from  the  hammer, 
burying  itself  in  the  malar  process  of  superior  maxillary  bone. 


496  OBAL  DISEASES  AND  SURGERY. 

Treatment. — With  probe,  searched  in  the  wound  for  the  foreign 
body ;  found  it  in  position  as  described,  with  very  oblique  track 
through  soft  parts.  Introduced  a  sharp  steel  instrument,  and,  after 
some  trouble,  succeeded  in  working  the  piece  loose ;  could  not,  how- 
ever, get  hold  of  it  with  forceps  without  such  manipulation  as  would 
evidently  enough  contuse  the  parts.  Introduced  a  director  down  to 
the  body,  and  cut  to  it;  removed  it  in  this  way  without  effort. 
Wound  closed  with  two  delicate  sutures,  and  the  cold-water  dress- 
ing applied;  in  three  or  four  days  the  parts  were  entirely  well,  with- 
out the  slightest  suppuration  having  occurred, — no  noticeable  scar 
being  left. 


CHAPTER    XXXII. 

OZ^NA. 

The  term  ozsena,  like  the  term  epulis,  is  a  somewhat  indefinite 
one,  and  is  to  be  first  considered  in  the  width  of  its  signification. 

Ozsna  is  from  the  Greek  oZrj,  signifying  stench,  and  the  terra 
is,  therefore,  in  reality  and  strict  justice,  applicable  to  any  ill-smell- 
ing condition.  By  universal  consent,  however,  it  has  been  restricted 
in  its  application  to  foul  conditions  about  the  nares  and  associate 
parts,  accompanied  with  offensive  discharge.  The  study  of  ozaena, 
then,  it  will  be  seen,  is  the  study  of  various  conditions,  and  may  be 
considered  under  the  following  heads  : 

1.  Accumulation  and  degeneration  of  the  common  antral  secre- 
tion. 

2.  Degenerated  pus  from  tooth-abscess  discharging  into  the 
antrum. 

3.  Ulceration  of  mucous  membrane  of  the  antrum. 

4.  Deteriorated  secretions  from  constitutional  causes. 

5.  Caries  of  the  osseous  walls  of  antrum  of  the  nares. 

6.  Ulceration  of  the  mucous  membrane  of  the  nares. 

7.  Caries  and  necrosis  of  the  osseous  boundaries  of  the  nares. 

8.  Lodgment  and  retention  of  foreign  bodies. 

'  The  first  of  these  conditions  is  most  frequently  observed  in  con- 
'  nection  with  the  ordinary  cold  in  the  head.  The  outlet  of  the  antrum, 
^  it  will  be  remembered,  is  by  an  opening  about  the  size  of  a  goose- 
I  quill  into  the  middle  meatus,  which  opening  is  circumscribed  by 
'mucous  membrane,  and  which  membrane,  as  the  result  of  conges- 
|tion,  can  very  well  occlude  this  outlet;  the  parts  being  in  this  con- 
'dition,  it  may  happen  that  the  pent-up  mucus  degenerates  and 
;  decomposes,  so  that,  on  the  subsi^nce  of  the  swelling,  the  escaping 
!  discharges  present  this  ofi'ensive  odor.  To  diagnose  this  character 
[of  ozaena,  it  is  only  necessary  to  connect  it  with  the  preceding 
^inflammation,  with  the  absence  of  specific  conditions,  and  with 
[the  readiness  with  which  it  yields  to  simple  treatment.  Of  course 
ithere  would  have  been  a  preliminary  feeling  of  the  sense  of  con- 
jgestion  on  the  part  of  the  patient ;  he  would  have  had,  to  express 
i  32  (  497  ) 


498  ORAL  DISEASES  AND   SURGERY. 

it  most  simply,  a  cold  in  the  head,  and  this  cold,  with  its  sense 
of  dryness  and  constriction,  would  have  grown  worse,  until,  with 
the  appearance  of  the  discharge,  he  would  have  experienced  a 
sense  of  relief;  the  discharge  implying  the  passing  away  of  the 
congestion  and  the  restoration  of  the  normal  circulation  and  secre- 
tion. 

To  cure  this  form  of  ozaena  requires  very  little  treatment, — indeed 
in  many  cases  no  treatment  at  all.  I  am  in  the  habit,  when  the 
discharge  continues  longer  than  two  or  three  days,  of  directing 
the  sniffing  up  the  nostril  of  the  affected  side  some  such  combination 
as  the  following : 

R.— ^th.  sulph.  ^i; 
Tinct.  iodiuii,  ^ij  ; 
01.  juniper.  5i-     M. 

If  this  fails  to  check  the  discharge,  I  then  employ  such  constitu- 
tional ti'eatment  as  seems  indicated.  Patients  in  whom  such  dis- 
charge exists  belong  to  one  of  two  classes,  the  plethoric  or  anaemic. 
"With  the  first,  the  treatment  demanded  is  depletory:  a  dose  or 
two  of  sulphate  of  magnesia  will  generally  be  all  that  is  demanded; 
although  in  a  few  instances  I  have  found  it  necessary  to  deplete 
from  the  veins.  With  the  second  class — and  this  is  by  far  the 
most  numerous — we  have  the  mucous  membrane  of  the  part  falling 
into  a  condition  analogous  to  the  urethritis  of  chronic  gonorrhoea : 
in  these  cases  tonics  are  at  once  to  be  resorted  to,  and  the  common 
combination  of  iron  and  quinia  is  perhaps  about  the  best  that  can 
be  prescribed : 

R. — Tinct.  ferri  chl.  §i ; 
Quiniae  sulph.  5i-     ^I- 
Sig.   15  drops  in  water  every  three  hours. 

2.  Fetid  discharges  depending  on  tooth-abscesses  —  abscesses 
which  discharge  into  the  antrum — find  their  cure,  as  a  rule,  imme- 
diately on  the  extraction  of  the  diseased  tooth.  If  this  should  not, 
however,  prove  to  be  the  case,  then  injections  are  to  be  made 
through  the  tooth  alveolus.  Iodine  is  an  admirable  base  for  all 
such  injections.  My  own  practice  would  be  first  to  control  the  odor 
with  the  permanganate  of  potash. 

R. — Potass,  permang.  5ss  to  j; 

Aqua,  ^viij.     M. 
Inject  pro  re  nata. 


OZ^NA.  499 

It  would  most  likely  be  quite  sufficient  to  use  this  injection  three 
times  a  day — after  which  the  following  should  be  thrown  in : 

B. — Tinct.  iodinii,  5i; 
Glycerin,  gi ; 
Acid,  tannicum,  '^si> ; 
Aqua  Cologn.  |i ; 
Aqua  pura,  ^iij.     M. 


Or, 
Or, 

Or, 


B. — Tinct.  capsici  comp.  5ss; 
Aqua,  3viij.     M. 

Chloroform,  ^i ; 
Spts.  aeth,  nit.  ^ss; 
Spts.  vin.  ^iv.     M. 

B. — Argent,  nit.  grs.  xxx; 
Aqua,  3vi.     M. 

Indeed,  any  stimulant  preparation  may  be  resorted  to,  although 
I  incline  to  believe  that  iodine  acts  the  most  happily. 

3.  Ozffina  from  ulceration  of  mucous  membrane  of  the  antrum  is 
not,  so  far  as  my  experience  allows  me  to  judge,  a  condition  of  fre- 
quent occurrence  ;  without  doubt  this  is  the  case  where  no  specific 
disease,  as  syphilis,  scrofula,  or  scurvy,  exists,  so  that,  meeting  with 
such  ozsena,  we  naturally  at  once  revert  to  the  constitutional  con- 
dition. To  discover  an  ulcer  within  the  antrum  is  a  matter  for 
diagnosis  by  exclusion,  and  thus  to  discover  it  is  not  at  all  a 
difficult  matter.  If  there  are  no  diseased  teeth  or  teeth  roots ;  no 
nasal  ulceration,  no  antral  dropsy,  no  acute  preliminary  conditions ; 
if  the  fetid  matter  flows  most  freely  when  the  suspected  antrum 
overlies  its  nasal  outlet,  then  Ave  will  generally  be  right  in  inferring 
an  ulcer  of  the  antrum  ;  but  an  ulcer  in  the  antrum  is  not  neces- 
sarily a  cause  of  oziena.  To  give  this  fetid  odor,  it  must  be  an  un- 
healthy ulcer,  by  which  is  meant  that  it  tends  to  degenerate  its  granu- 
lations, rather  than  to  organize  them.  An  ulcer,  says  Mr.  Cooper, 
may  be  defined  to  be  "a  granulating  surface,  secreting  matter;"  and 
this  is  certainly  true  of  most  ulcers,  particularly  if  we  replace  the 
term  secreting  with  the  term  making;  for  the  matter  given  off  is,  1 
imagine,  nothing  but  degenerated  lymph-corpuscles,  to  which  the 
parts  lacked  strength  to  give  force  of  organization.  A  healthy  ulcer 
may  be  seen  in  any  accidental  sore  tending  to  rapid  self-cure ;  there 


500  ORAL  DISEASES  AND  SURGERY. 

is  here  little,  or  perhaps  no  matter,  for  the  reason  that  ever}- 
particle  of  the  exuded  lymph  of  repair  has  in  it  vitality  sufficient 
for  its  organization.  An  unhealthy  ulcer,  on  the  contrary, — and 
by  such  an  ulcer  we  mean  an  adynamic  one, — gives  off  more  or 
less  pus  ;  it  throws  out  its  i-eparative  lymph  just  as  does  the  healthy 
one,  but  the  viability  of  such  lymph  differs  materially  from  the  ex- 
udation of  the  former  ulcer.  Thus,  according  to  the  nature  and 
character  of  such  degeneration,  we  have  the  produced  pus:  ich- 
orous, a  thin,  watery,  acrid  discharge  ;  scrofulous,  a  cheesy,  curd- 
like  pus;  sanious,  a  thin,  sizy  discharge;  glutinous  and  viscid,  as 
in  sordes,  etc. 

Now,  whether  any  or  all  these  kinds  of  ulcers  should  give  us  the 
fetor  of  ozaena,  would  depend  on  circumstances  ;  not  the  least  im- 
portant of  which  would  be  the  state  of  the  atmosphere,  and  the 
cleanliness  preserved.  Laudable  pus,  issuing  from  a  healthy  wound, 
will,  in  hot  weather,  become  in  a  very  short  time  quite  offensive,  as 
is,  unfortunately,  too  freely  illustrated  in  hospital  practice.  Certain 
ulcers  are,  however,  in  themselves  offensive.  Every  one  has  had 
occasion  to  observe,  at  some  time  or  other,  the  disgusting  odor  aris- 
ing from  the  saliva  of  particular  persons.  I  recall,  even  to  this  day, 
a  certain  schoolmaster,  the  odor  of  whose  spittle,  employed  to  rub 
sums  from  my  slate,  always  made  me  sick.  This  kind  of  saliva, 
and  this  odorous  ulcer,  belong  to  the  alkaline  class  of  people.  Give 
such  persons  acid  :  they  always  need  it ;  I  never  knew  an  exception. 

A  simple  ulcer  of  the  sinus,  that  is,  one  not  associated  with 
osseous  diseases,  is  to  be  treated  in  the  twofold  direction  of  its  con- 
stitutional and  local  requirements.  To  treat  an  ulcer  justly,  calls 
for  an  understanding  of  the  conditions  on  which  ulcers  depend ;  and 
as  ulcers  of  various  signification  so  frequently  present  themselves 
about  the  mouth  and  throat,  it  may  not  be  a  digression  to  make  a 
hasty  review  of  so  enlarged  and  important  a  subject. 

Ulceration  is  the  absorption  or  the  breaking  down  of  some  con- 
stituent part  of  the  body.  Its  great  cause  is  inflammation.  In- 
flammation is  always  preceded  and  excited  by  irritation.  The 
term  irritation  is  a  comprehensive  one,  and  covers  every  source  of 
offense  to  the  human  body.  Thus  one  man  has  an  ulcer,  the  result 
of  an  inflammation  excited  and  perhaps  kept  up  by  the  presence  of 
some  foreign  body,  as,  for  example,  a  ball,  a  splinter  of  wood,  a 
particle  of  dust,  etc.  An  ulcer,  says  Richerand,  is  from  a  cause  in- 
herent in  the  economy,  and  differs  from  a  wound,  which  is  always 
idiopathic,  in  being  symptomatic.     A  second  man  has  an  ulcer,  the 


OZJEXA.  50^ 

result  of  a  localized  inflammation,  predisposed  bj  the  presence 
within  his  system  of  some  specific  taint.  These  ulcers,  a  glance 
would  exhibit,  must  vary  widely  in  their  character,  and  even  more 
so  in  the  treatment  demanded  for  their  cure.  Thus  it  is  that  we 
speak  of,  and  think  about,  ulcers  in  the  way  of  their  signification. 
We  have  simple  purulent  ulcers,  venereal  ulcers,  scrofulous  ulcers, 
scorbutic,  varicose,  and  cancerous  ulcers;  the  character  of  each  being 
expressed  by  its  adjectival  prefix.  A  simple  purulent  ulcer  is  a  sore, 
the  result  of  some  local  accident,  and  is,  most  likely,  self-curing;  a 
venereal  ulcer  is  one  excited  and  kept  alive  by  the  presence  in  the 
system  of  the  venereal  poison  ;  the  scrofulous,  scorbutic,  and  can- 
cerous alike  depend  on  dyscrasic  conditions;  the  varicose  on  certain 
obstructions  in  the  venous  system,  etc.  To  secure  a  cure,  in  the 
first  of  these  classes  of  ulcers,  nothing  more  is  necessary  than  to 
protect  them  from  adverse  influences.  A  varicose  ulcer,  to  be  gotten 
well,  must  be  converted  into  a  simple  one  by  treatment  directed  to 
the  trouble  in  the  circulation ;  a  cancerous,  scorbutic,  or  scrofulous 
ulcer  is  only  to  be  permanently  cured  by  obliterating  the  cachexia. 
There  is  nothing  obscure  in  the  appreciation  of  these  facts ;  any 
difficulty  is  in  meeting  the  indications.  Ulcers,  it  is  true,  are  pre- 
sented under  a  great  variety  of  names ;  but  these  variations  have 
reference  alone  to  varieties  in  expression.  Thus,  the  carious 
ulcer  implies  that  the  condition  is  dependent  on  the  presence  of 
dead  or  dying  bone ;  a  callous  ulcer  is  one  having  an  indurated 
circumference  ;  a  fungous  ulcer,  one  where  the  granulations  of  repair 
are  in  excess ;  a  sinuous  ulcer  is  one  constituting  the  orifice  of  a 
canal  leading  to  a  deeper  than  the  manifested  disease ;  an  irritable 
ulcer  is  one  that,  from  internal  or  external  causes,  has  become  tender 
and  excited ;  a  phagedenic  ulcer  is  one  that  tends  to  take  on  gan- 
grenous action  ;  a  sordid  ulcer  is  one  discharging  a  dirt3--looking, 
glutinous  matter;  and  so  on,  each  of  the  many  appellations  being 
simply  an  expression  of  some  distinctive  peculiarity.  Now,  one 
man,  having  syphilis,  gets  a  rheumatism  in  his  joints,  another  gets 
an  ulcer  on  his  tibia.  In  these  two  cases  the  important  features 
of  treatment  are,  however,  to  be  precisely  alike ;  both  patients  must 
have  an  antisyphilitic  medication ;  the  local  applications  are  simply 
adjuncts.  An  ulcer  simple  in  its  character,  situated  over  or  upon 
some  part  in  frequent  motion,  is  apt  to  assume  the  irritable  aspect ; 
an  ulcer  the  result  of  an  idiopathic  influence,  if  occurring  on  a  person 
of  weak  and  typhoid  condition,  is  almost  certain  to  assume  the 
chronic  or  indolent  form  ;  an  ulcer  engrafted  by  external  cause  on  a 


502  ORAL  DISEASES  AND  SURGEBY. 

depraved  constitution  is  always  more  or  less  influenced  by  the  vice, 
and  such  vice  must  be  considered  in  its  treatment;  and  so,  what- 
ever may  be  the  extent  of  the  review,  this  wide  collateral  relation- 
ship keeps  itself  in  the  foreground. 

To  return,  then,  to  ulcers  in  the  antrum.  We  are  prepared  to 
recognize  that  such  ulcers  may  be  of  various  signification,  and  may, 
for  their  cure,  demand  a  various  character  of  treatment.  So  far  as  the 
odor,  however,  is  concerned,  all  will  benefit  by  the  common  primary 
treatment  of  cleanliness  and  antiseptic  injections.  To  correct  the 
fetor  in  a  chronic  case,  it  generally  becomes  a  necessity  either  to 
trephine  through  the  canine  fossa,  or  to  extract  one  of  the  under- 
lying teeth  and  get  into  the  cavity  through  its  alveolus ;  the  latter 
mode  is  decidedly  to  be  preferred.  A  plan,  however,  that  may  be 
tried,  consists  in  keeping  a  tuft  of  cotton  or  fine  sponge  in  the 
nostril,  and  frequently  saturating  it  by  the  sniffing  into  it  of  an  anti- 
septic. The  entrance  into  this  cavity,  however,  through  the  alveo- 
lus of  a  tooth  is  one  of  the  simplest  procedures  in  surgery,  de- 
manding only  that  the  operator  shall  recognize  the  position  of  the 
cavity  as  influenced  by  the  shape  of  the  jaw.  Any  spear-shaped 
instrument  will  answer  to  make  the  opening ;  to  keep  it  patulous, 
it  is  only  necessary  to  introduce,  after  each  operation  of  injection, 
a  tent  of  cotton  or  sponge.  As  an  injection,  the  following  combina- 
tion may  be  employed : 

R. — Acidi  carbolici,  gtt.  xx  ; 
Glycerin,  ^ss  ; 
Acid,  tannic,  gr.  v  ; 
Aqua,  ^vi.     M. 
Or, 

R. — Spts.  viu.  3i ; 

Creasotum,  gtt.  x ; 
Aqua,  ^vi.     M. 

Or,  as  suggested  on  page  498,  the  permanganate  of  potash  in  the 
proportion  of  from  two  to  ten  grains  to  the  ounce  of  water,  as  indi- 
cated. 

Associated  with  such  antiseptic  treatment,  and  which  we  employ 
in  every  case  of  ozaena,  whatever  may  be  its  origin,  Ave  connect 
the  specific  or  peculiar  treatment  demanded  by  each  special  case, — 
the  understanding  of  which  treatment  presupposes  and  necessitates 
the  understanding  of  disease  in  general,  and  can  conform  to  no 
special  rules. 


OZ^NA.  gQ3 

It  is  true  that  for  certain  diseases  we  have  certain  medicaments 
which  we  have  come,  perhaps  unadvisedly,  to  consider  too  much  in 
the  light  of  specifics.  Thus,  in  syphilis  the  mercurials  are  much 
depended  on ;  so  that,  having  an  ulcer  of  such  origin  to  treat,  a 
constitutional  medicine  might  be  prescribed,  as  follows  : 

B- — Syrup,  ferri  pyrophos.  Jvi ; 
Hydrarg.  bichl.  gr.  iv.     M. 
Sig.  A  teaspoonful  three  times  a  day. 


Or, 


Or, 


R. — llydrarg.  bichl.  gr.  ij  ; 
Potass,  iod.  5ij ; 
Fid.  ext.  sarsaparilla,  ^viij.     M. 
Sig.  A  tablespoonful  three  times  a  day. 


B. — llydrarg.  chl.  mite,  gr.  iv ; 
Sacch.  alb.  pulv.  ^ss.     M. 
Divide  into  eight  powders. 
Sig.  One  three  times  a  day,  followed,  after  each  eight  have  been 
taken,  by  a  Seidlitz  powder. 

Mercury  is  to  be  considered  as  an  active  force,  striking  at  the  para- 
site of  syphilis,  destroying  it ;  and  while  it  is  very  well  thus  to  kill  such 
parasites,  it  is  quite  as  well  to  remember  that  the  harm  of  the  agent 
employed  must  be  constantly  met  and  counterbalanced  ;  this  we  do 
by  keeping  up  and  supporting  the  system,  so  that  I  think  it  will 
commonly  be  found  that  syphilitic  ulcers  require  wholesome  food, 
fresh  air,  proper  exercise,  judicious  bathing, — in  short,  the  employ- 
ment of  every  means  that  tends  to  the  maintenance  of  the  general 
health. 

In  the  mercurial  ulcer — which  is  far  more  common  than  the  syphi- 
litic, granting  the  true  syphilitic  to  exist — the  general  and  local  use 
of  the  chlorate  of  potash  is  found  to  act  very  well.  The  medicine, 
dissolved  in  water,  may  be  given  in  doses  of  ten  grains,  repeated 
four  or  five  times  a  day  ;  the  injection  should  be  not  less  in  strength 
than  a  saturated  solution.  The  character  of  a  mercurial  ulcer  is 
discovered  by  associating  the  local  lesion  with  the  existing  general 
dyscrasias. 

Scrofulous  ulcers  are  judged  by  the  appearance  of  the  sore,  the 
nature  of  the  discharge,  and  the  existence  of  the  disease  in  the  pa- 
tient at  large.  A  scrofulous  subject,  while  not  always  bearing  the 
clearest  general  evidences  of  the  disease,  yet  generally  has  some  one 


504  ORAL  DISEASES  AND  SURGERY. 

or  more  features  that  will  allow  us  to  distinguish  the  condition. 
General  features  associated  with  scrofula  may  be  enumerated  as  fol- 
lows. The  first  manifestation  occurs  generally,  not  always,  at  the 
period  of  first  dentition,  the  symptoms  being  irregular  appetite,  au 
ill-smelling,  inspissated  mucus,  swelling  of  the  superficial  glands  of 
the  ucck.  Continued  manifestations  advance  with  age,  presenting 
subcutaneous  lymph  eflTusion,  particularly  about  the  calves  of  the  legs 
and  the  outside  of  the  thighs ;  various  eruptions,  inflammation,  and 
suppuration  of  joints,  especially  the  hip,  knee,  and  thumb  joints  ;  a 
flaccid,  enlarged  condition  of  the  tonsil  glands,  susceptibility  to  at- 
mospheric changes,  inability  to  endure  physical  fatigue,  impoverish- 
ment of  the  blood,  general  asthenia.  Scrofulous  subjects  are  gener- 
'ally  languid  in  their  movements,  and  without  impressibility  ;  not 
always,  however,  for  it  is  a  well-known  fact  that  many  of  the  most 
precocious  and  bright  persons  end  their  effulgence  in  phthisis.  In 
short,  the  history  of  scrofula  is  the  history  of  phthisis ;  it  matters 
little,  so  far  as  a  general  effect  upon  an  individual  is  concerned, 
whether  the  tubercle  deposits  itself  in  the  lung  or  in  the  ganglia,  or 
diffuses  itself  over  the  system  at  large. 

Scrofulous  ulcers  are  always  unhealthy  in  appearance,  being  cov- 
ered with  a  dirty  yellowish  aplastic  matter,  irregular  about  their 
edges,  generally  bluish  or  purple,  more  or  less  undermined,  and  dis- 
charging an  ichorous,  flaky  pus  ;  local  stimulation  meets  with  little 
or  no  response,  and,  for  the  reason  of  the  general  deficiency  in  vi- 
tality, the  parts  around  ai"e  usually  indurated  from  interstitial  deposits, 
chronically  congested,  and  looking  altogether  indolent  and  ill-con- 
ditioned. 

The  treatment  of  scrofulous  ulceration  is  (in  our  present  knowl- 
edge of  the  disease)  simply  a  treatment  of  building  up.  Unacquainted 
with  the  character  and  causes  of  the  diseases,  we  direct  our  aim  to 
so  lift  up  the  life-forces  that  a  sufBcient  inherent  vitality  may  be  de- 
veloped to  throw  off  or  overmaster  the  depressing  influence.  Exer- 
cise, tonic  medicaments,  cold  bathing,  salt  and  mountain  air,  rare  or 
raw  meats,  generous  liquors,  all  are  useful  means  to  such  an  end. 
Iodide  of  potassium  has  long  had  a  reputation  in  this  disease,  also 
barium,  iodide  of  iron,  syrup  of  the  phosphates,  cod-liver  oil,  phos- 
phoric acid,  etc.  My  own  individual  opinion  and  experience  is,  that 
wrapping  one's  self  in  a  wet  sheet  on  getting  out  of  bed,  and  securing 
vigorous  reaction  by  a  good  hand-rubbing,  and,  after  such  operation, 
drinking  the  yolk  of  a  fresh  eg^  drowned  in  good  brandy  or  whisky, 
is  better  than   any  medicine  proper  yet  prescribed.     Certain  I  am 


OZ^NA.  5()5 

that  I  have  seen  this  treatment  do  such  good  as  warrants  the  com- 
mendation these  remarks  would  give  it. 

We  always,  however,  do  something  to  a  local  disease,  if  for  no 
other  reason,  from  mere  force  of  habit.  We  can  use  with  these 
ulcers  any  of  the  applications  referred  to  a  few  pages  back,  and  any 
one  of  them  is  about  as  good  as  the  other,  or  we  may  use  them  one 
after  the  other. 

Syphilitic  ozsena  from  ulceration  of  the  antral  mucous  meml)rane 
must  be,  as  remarked,  an  exceedingly  infrequent  affection.  Not  so, 
however,  with  ulceration  from  such  cause  in  the  nares ;  such  a  con- 
dition is  quite  common.  When  you  have  a  case  in  which  dirty  clotty 
scabs  are  constantly  being  received  into  the  handkerchief,  and  much 
offensive  sanies  is  discharged  from  the  nose,  you  may  feel  well  sat- 
isfied that  you  have  a  case  of  syphilitic  ulceration,  and  particularly 
may  you  rest  satisfied  in  your  diagnosis  if  any  evidences  of  the  dis- 
ease exist  in  other  parts  of  the  body.  Syphilitic  ulceration  of  the  nose 
has  frequently  been  confounded  with  a  commencing  polypus;  but  the 
conditions  are  so  dissimilar  that  only  the  most  culpable  carelessness 
could  fail  to  distinguish  them.  In  the  first  condition  there  are  the 
fetid  discharge,  and  the  association  with  the  anterior  train  of  acci- 
dents ;  a  scab  soon  comes  away,  and  a  temporary  cessation  of  the 
obstruction  ensues  In  the  latter  disease  the  obstruction  is  gradual 
a,nd  coutinuous ;  there  are  no  fetid  clots,  and  no  anterior  accidents 
of  association:  blowing  the  nose,  in  the  one  case,  most  likely  re- 
lieves for  the  moment ;  in  the  second,  it  throws  forward  the  polypus 
so  that  we  can  see  and  feel  it. 

Syphilitic  ulcers  within  the  nose  attack  equally  any  location, 
and  possess  the  most  unfortunate  tendency  to  enlarge  and  bur- 
row, so  that,  if  not  successfully  combated,  in  a  very  short  time 
the  bony  framework  is  involved,  thus  giving  the  deformities  so 
common. 

A  patient  with  a  syphilitic  ulcer  developing  in  his  nose,  com- 
plains first  of  a  feeling  of  congestion.  We  come  to  our  conclusions 
because  we  observe  other  certain  secondary  indications.  A  few  days, 
more  or  less,  pass,  and  he  is  troubled  with  a  discharge;  this,  at 
first,  is  very  little  or  perhaps  not  at  all  offensive.  Very  soon,  how- 
ever, he  remarks  the  odor,  and  the  discharge,  which  continues  to 
increase,  frequently  becomes  so  profuse  that  twenty  or  thirty  pocket- 
handkerchiefs  are  necessary  for  his  daily  use.  Occasionally,  and 
sometimes  very  frequently,  dirty,  gluey  clots  or  scabs  come  away, 
and  the  ulcer,  if  seen,  is  noticed  to  present  a  reasonably  healthy 


506  ORAL   DISEASES  AND   SURGERY. 

look,  something,  for  example,  as  a  chancre  would  look  when  only 
half  destroyed  and  casting  oflf  its  slough.  If  unconibated  and  un- 
conquered,  the  ulcer  eats  deeper  and  deeper,  until  the  bone  is 
reached,  Avhich,  in  its  turn,  succumbs,  giving  us  caries,  or,  much 
more  likely,  necrosis.  Arrived  at  this  stage,  we  have,  indeed,  a  most 
formidable  condition,  and  it  is  not  at  all  unlikely  that,  in  defiance  of 
every  effort,  more  or  less  deformity  will  I'esult. 

An  ulcer  situated  in  the  anterior  part  of  the  nares  is  indicated  by 
the  forced  expirations  of  the  patent.  Situated  well  back,  he  relieves 
himself  by  forced  inspirations  ;  occasionally,  however,  from  the  very 
beginning  the  pituitary  membrane  becomes  so  thickened  and  en- 
gorged that  the  passage  of  air  through  the  tube  is  almost  shut  off: 
in  these  cases  the  trouble  is  indicated  by  excessive  restlessness. 

It  is  not  by  any  means  always  the  case  that  nasal  ostitis  is 
secondary  to  ulceration:  on  the  contrary,  the  cases  are  frequent 
enough  where  the  bone  becomes  primarily  diseased  and  where  the 
ulcer  is  simply  the  associated  lesion.  Syphilitic  ostitis  very  fre- 
quently ends  in  necrosis;  and  more  particularly  is  this  the  case 
where  the  turbinated  bones  are  the  ones  affected.  The  vomer,  how- 
ever, is  the  one  most  frequently  necrosed  in  syphilis, — that  is  to 
say,  the  most  frequently  attacked  ;  and  this  is  brought  about  in 
three  ways :  first,  from  a  primary  ulceration  of  its  mucous  cover- 
ing ;  second,  by  the  deposition  of  submucous  tubercles ;  third,  by 
the  direct  affection  of  the  bone.  When  ostitis  attacks  the  vomer  or 
any  other  bone,  our  best  efforts  are  to  be  directed  to  the  resolution 
of  the  inflammation.  To  secure  this  end,  we  resort  to  such  local 
means  as  seem  indicated  by  the  peculiar  features  of  the  case.  The 
treatment  would  be  that  applicable  to  inflammation  anywhere ;  it 
could  be  influenced  by  the  temperament  of  the  patient  and  the 
stage  of  the  disease ;  locally  we  have  nothing  at  this  time  to  do 
with  its  specific  character ;  we  have  simply  to  treat  a  perverted 
condition  of  the  circulation  of  the  part.  Constitutionally,  however, 
its  origin  is  to  attract  our  closest  scrutiny ;  and,  in  connection  with 
the  local  remedies  employed,  antivenereals  must  be  depended  upon 
as  our  strongest  supports. 

The  diagnosis  of  inflammation  of  the  nasal  boundaries  is  not  diffi- 
cult to  make  out.  When  the  vomer  is  the  bone  attacked,  the  patient 
suffers  from  sharp  pains,  referred  to  the  root  of  the  nose ;  he  has 
headache,  always  increased  by  the  recumbent  position.  If  the  in- 
flammation exists  in  the  anterior  part,  pressure  on  the  cartilage 
increases  the  pain. 


OZMNA.  50y 

The  nasal  bones,  when  affected,  exhibit  an  overlying  congested 
skin ;  pressure  on  the  bridge  is  responded  to  by  much  pain ;  the 
lachrymal  secretions  are  affected,  and  not  unfrequently,  because  of 
the  congestion  in  the  ductus  ad  nasum,  run  over  the  cheek.  The 
turbinated  bones,  when  the  seat  of  the  inflammation,  yield  a  sore- 
ness to  the  lateral  aspects  of  the  canal,  and  respond  quickly  to 
pressure  thereon  exerted. 

Whichever  of  these  bones  may  be  the  one  affected,  its  history,  so 
far  as  ozaena  is  concerned,  is  the  same  in  signification.  If  the  inflam- 
mation is  not  arrested,  necrosis  or  caries,  partial  or  complete,  results. 
Soon  a  discharge  makes  its  appearance,  disgustingly  foul  if  the 
case  is  one  of  necrosis,  and  more  or  less  offensive,  and  mixed  with 
osseous  particles,  if  it  is  caries. 

Antivenereal  treatment  is  a  treatment  of  building  up.  You  can- 
not hope  to  arrest  syphilis  when  it  has  passed  to  its  tertiary  mani- 
festations in  any  other  way.  Limit  and  circumscribe  the  local  inflam- 
mation as  much  as  you  can ;  and  to  do  this  you  will  generally  find 
that  stimulants  act  a  better  part  than  depressants.  An  excellent 
injection  is  a  combination  of  iron,  iodine,  quinine,  and  glycerin. 

B.— Tinct.  ferri  chl.  5i ; 
Quiniae  sulph.  gr.  xxv; 
Tinct.  iodinii, 
Glycerin,  aa  |i ; 
Aqua,  ^iv.     M. 
Sig.  Inject,  or  brush  over  and  about  the  parts,  three  times  a  day. 

Give  iron  and  quinia  internally:  it  is  scarcely  probable  that  a 
patient  having  syphilitic  necrosis  needs  a  mercurial  course ;  in- 
deed, it  is  much  more  likely  that  he  has  already  been  so  over- 
drugged  with  this  medicine  that  his  trouble  is  mercurio-syphilitic, 
rather  than  syphilitic  alone.  Iodide  of  potassium  is  recommended 
and  freely  prescribed  in  these  tertiary  conditions :  it  may  be  given 
in  doses  of  from  ten  to  twenty  grains  dissolved  in  water  or  in  the 
fluid  extract  of  sarsaparilla.  But  good  rare  roast  beef,  poultry,  a 
daily  glass  of  malt  liquor,  boat-rowing,  wrestling,  horseback-riding, 
systematic  bathing,  these  are  the  reliable  medicines,  and  may 
elevate  the  vital  forces  to  an  ability  iper  vias  naturales  to  throw  off 
the  disease.  It  is  confessedly  hard  to  cure  syphilis  when  it  has 
thus  taken  hold  of  the  system  ;  and  when  it  inflames  a  bone,  par- 
ticularly a  small  one,  the  patient  is  lucky  if  he  escape  without  its 
complete  destruction. 


508  ORAL  DISEASES  AND  SURGERY. 

Necrosis,  partial  or  complete,  implies,  of  course,  the  existence 
of  a  sequestrum  ;  and  the  getting  away  of  this  dead  part  implies 
very  generally  the  cure  of  the  oza3na.  Particularly  is  this  the 
case  when  the  death  is  limited  to  the  single  bone  or  piece.  To  get 
away  this  piece  is  then  one  of  the  most  important  features  in  the 
treatment.  How  is  it  to  be  done  ?  Simply  wait  until  the  probe 
reveals  that  it  is  loose ;  if  it  may  not  be  taken  away  through  the 
orifice  of  the  sinus  it  has  itself  created,  we  have  only  to  enlarge 
in  any  convenient  way  such  sinus,  and  then  lift  the  piece  away. 
If,  after  the  removal  of  such  dead  bone,  we  find  the  discharge 
continuing,  but  modified  as  to  character  and  odor,  we  infer  the 
necessity  for  stimulation,  and  use  the  iodine,  or  iodine  and  iron,  or 
the  combination  with  tannin  and  glycerin,  as  seems  to  be  indicated. 
It  might  be,  however,  that  neither  the  discharge  nor  the  odor 
decreased :  in  such  cases  we  are  seldom  wrong  in  inferring  that 
more  dead  or  dying  bone  is  in  the  wound,  and  the  treatment  first 
employed  is  to  be  renewed.  When  tertiary  syphilis  has  associated 
with  it  severe  nocturnal  pains,  great  relief  is  frequently  secured 
from  the  administration  of  the  iodide  of  potassium,  particularly  if 
combined  with  minute  doses  of  phosphorus — say  five  drops  of  the 
acid,  phosphoric,  dilut.;  as  a  dose  it  is  to  be  remembered,  however, 
that,  because  of  the  relationship  of  the  potash  with  the  mucous 
membranes,  in  many  persons  even  very  small  doses  will  excite  much 
irritability  in  the  air-passages,  thus  seeming  to  increase  instead  of 
allaying  the  trouble.  With  such  patients  we  must  diminish  the 
dose  of  the  iodide  pro  re  nata. 

Bromide  of  potassium  is  now  frequently  employed  to  procure  rest 
and  tranquillity.  It  is  commonly  prescribed  in  doses  of  ten  grains ; 
but  forty  or  fifty  will  be  found  the  better  dose.  It  is  best  given  in 
a  little  water  just  as  the  patient  is  about  to  get  into  bed. 

Lodgment  and  Retention  op  Foreign  Bodies. — In  the  use  of 
cotton  or  sponge  about  the  nares,  care  is  to  be  taken  that  the  pellets 
do  not  escape  attention  and  remain  lodged  in  the  passages.  Some  of 
the  most  offensive  and  resisting  discharges  occasionally  have  their 
cause  in  this  direction.  Rhinolites — calculi  varying  in  size  from  a 
pea  to  that  of  a  pigeon's  %g^ — sometimes  form  in  the  canals,  and,  by 
inducing  ulceration  and  collecting  debris,  become  the  source  of 
ozaena.  Peas,  rags,  buttons,  and  sundry  other  articles  are  not  un- 
frequently  found  in  the  nares,  thrust  there  by  children  of  experi- 
mental proclivities,  any  of  which  may,  of  course,  become  a  source 
of  offense. 


OZ.ENA. 


509 


The  removal  of  foreign  bodies  from  the  nares  is  always  to  be 
effected  as  speedily  and  with  as  little  injury  to  the  parts  as  possible. 
A  plan  that  may  first  be  tried  is  to  place  the  patient  in  a  strong 
light  and  search  the  parts  with  very  delicate  forceps:  if  the  body  can 
be  seen,  it  may  thus  generally  be  removed.  Another  plan  consists 
in  giving  a  pinch  of  snuS"  and  compressing  the  unobstructed  nostril : 
the  effort  of  sneezing  will  not  unfrequently  throw  the  body  a  con- 
siderable distance.  Still  another  plan  is  to  compress  the  unobstructed 
nostril  and  blow  into  the  mouth,  thus  forcing  it  out.  An  annealed 
wire,  bent  into  the  form  of  a  loop  and  passed  over  the  body,  is  very 
frequently  employed  with  satisfactory  success ;  a  flexible,  blunt, 
double  hook  is  also  used  with  advantage.  The  syringe  is  some- 
times found  beneficial,  the  obstruction  being  washed  back  into  the 
throat. 


CHAPTER    XXXIII. 

FRACTURES  OF  THE  MAXILLARY  BONES. 

Fractures  of  the  maxillary  bones  may  be  divided  into  two  classes, 
simple  and  complicated.  The  first  applies  to  such  cases  as  are  with- 
out external  or  associate  injury,  implying  a  simple  break  in  the  con- 
tinuity of  the  bone.  The  second  applies  to  cases  associated  with 
comminution  of  the  bone,  to  external  lesions,  injury  to  vessels,  to 
teeth, — in  short,  any  and  every  condition  which  alters  the  fracture 
from  that  of  a  simple  to  one  of  a  compound  character. 

The  inferior  maxilla,  from  the  exposure  of  its  position,  from  its 
shape,  and  from  its  office,  is  much  more  liable  to  the  accident 
of  fracture  than  either  of  the  superior — the  accident  being  com- 
monly the  result  of  blows,  falls,  kicks,  etc.  These  fractures  will,  in 
the  majority  of  cases,  outside  of  gunshot  injuries,  be  found  asso- 
ciated with  the  body  of  the  bone,  the  rami  escaping,  from  the  fact 
that  a  force  brought  to  bear  upon  them  slips  the  articulation  easier 
than  it  may  break  the  bone. 

The  weakest  part  of  a  bone  would  most  naturally  be  the  part  to 
yield  in  a  diffused  blow.  In  most  inferior  maxillae  this  weakest 
point  is  found  to  be  the  line  of  the  roots  of  the  canine  teeth ;  hence 
the  most  frequent  seat  of  fracture  in  the  bone  is  in  this  line,  either  to 
the  right  or  left,  as  influenced  by  the  direction  of  the  force.  This, 
however,  as  would  be  inferred,  applies  to  an  unbroken  dental  arch  ; 
when  teeth  have  been  lost,  and  the  process  removed,  the  situation 
of  this  weakest  part  is  materially  altered.  In  gunshot  injuries,  acci- 
dents from  the  passage  of  a  wheel  over  the  jaw,  or  similar  applica- 
tions of  force,  fractures  occur,  of  course,  at  the  seat  of  such  appli- 
cations, and  follow  no  rule.  In  the  work  of  Prof.  Hamilton  on 
Fractures,  in  twenty-four  recorded  cases  of  breaks  in  the  inferior 
maxillary  bone,  one  was  perpendicular  through  the  symphysis,  twelve 
were  through  the  body,  five  through  the  angle.  Of  the  twenty-four, 
eleven  were  of  a  double  or  triple  character,  the  direction  of  the 
fracture  being  mostly  oblique,  both  as  direction  is  concerned,  and 
the  face  of  the  break. 
(510) 


FBACTVRES  OF  THE  MAXILLARY  BONES.       511 

It  is  singularly  the  case  that  most  fractures  of  the  body  of  the 
lower  jaw  are  compound,  the  opening-  existing  on  the  lingual  aspect ; 
this  seems  to  be  the  result  of  the  easy  lacerability  of  the  gum  tissue 
combined  with  the  quick  displacement  inward  of  the  fractured  part. 
This  exposure  of  the  bone  seems,  in  many  mouths,  to  be  of  no  very 
material  consequence.  In  others,  however,  it  is  quite  the  reverse 
the  saliva  thus  allowed  to  come  in  contact  with  the  bone  degenerat- 
ing and  deteriorating  the  tissue. 

Fractures  from  blows  of  the  fist,  or  similar  concentrated  forces,  are 
apt  to  be  single ;  from  falls,  they  are  apt  to  be  multiple ;  from  kicks 
of  animals,  comminuted.  A  common  cause  of  fracture,  familiar  to 
every  dentist,  is  found  in  the  extraction  of  teeth  having  large  and 
bifurcating  roots  ;  luckily,  however,  such  fractures  are  not  of  a  seri- 
ous nature,  generally  being  confined  to  the  alveolar  process,  although 
cases  are  on  record  where  such  accidents  have  been  so  extensive  and 
severe  as  to  cost  the  life  of  the  patient.  Complete  division  in  the 
continuity  is,  however,  rare,  very  few  cases  having  occurred. 

The  symptoms  denotive  of  a  fracture  are  seldom  or  never  obscure. 
There  are,  first,  the  mobility  at  the  break,  and  the  crepitation;  second, 
when  the  break  exists  in  the  body,  there  is  the  loss  of  harmony  in  the 
line  of  the  teeth,  the  short  fragment  being  pulled  upward.  If  the 
fracture  be  multiple,  irregularities  will  be  produced  in  the  line  of  the 
arch,  and  in  the  articulation.  If  the  freed  portion  be  the  anterior  or 
chin  part,  it  will  be  dragged  downward  and  backward  by  the  action 
of  the  genio-hyoid,  byoglossus,  and  digastric  muscles.  If  it  be  at  the 
line  of  the  cuspid  tooth  and  at  the  upper  portion  of  the  ramus,  the 
fragment  will  be  displaced  inward  by  the  action  of  the  mylo-hyoideus, 
upward  by  the  action  of  the  masseteric,  and  forward  by  the  action 
of  the  pterygoidei.  If  the  fracture  be  single,  and  beneath  the  attach- 
ment of  the  masseter,  crepitation  will  be  present,  but  little  displace- 
ment. If  the  neck  of  the  bone  is  broken,  the  body  is  dragged  forward 
by  the  action  of  the  pterygoid,  crepitation  and  mobility  will  be  very 
apparent,  and  much  pain  will  attend  the  movements  of  the  jaw,  pro- 
duced by  the  displacing  action  of  the  temporalis. 

Pain,  soreness,  inability  to  masticate,  inflammatory  phenomena, 
impediment  to  speaking  or  swallowing  associate  with  and  charac- 
terize the  accident, — in  short,  the  history  of  a  fractured  jaw  is  the 
history  of  a  fracture  anywhere  else,  allowing  for  differences  in  ofiice. 

Fractures  of  the  superior  maxilla  are  quite  infrequent,  and  when 
they  occur,  except  from  extraordinary  causes,  demand  little  attention 
outside  of  that  which  pertains  to  the  injury  as  a  contusion.     Of  such 


512  ORAL   DISEASES  AND   SURGERY. 

fractures  I  have  treated  a  number  which  surprises  me,  considering 
the  rarity  of  the  accident;  but  in  no  instance,  outside  of  the  alveolar 
fractures,  have  I  met  with  a  displacement  which  required  apparatus 
for  its  cure.  Indeed,  the  cellular  character  of  these  bones,  and  the 
existence  of  the  antra,  permit  of  such  yielding  that  depression  of  the 
substance  of  the  bone  commonly  forms  the  displacement ;  hence  the 
associated  frequency  of  caries  with  such  accidents,  the  vitality  of 
the  part  being  lowered  or  destroyed.  It  is  not,  however,  to  be  un- 
derstood that  displacements  do  not  occur  ;  the  force  of  an  injury  may 
be  great  enough,  as  cases  are  on  record  to  show,  to  displace  the 
bones  in  mass.  In  Mr.  Heath's  work  is  the  record  of  a  case  taken 
from  the  Chirurgical  Treatise  of  Richard  Wiseman,  which  is  a 
marked  example  of  such  displacement.  The  patient  was  a  lad  eight 
years  old,  who  had  received  a  blow  on  the  middle  of  the  face  so 
severe  that  he  appeared  at  first  to  be  dead,  and  afterwards  lay  in 
prolonged  coma.  "When,"  says  Mr.  Wiseman,  "I  first  saw  the 
boy,  he  presented  a  strange  aspect,  having  his  face  driven  in,  his 
lower  jaw  projecting  forward.  I  knew  not  where  to  find  any  purchase, 
or  how  to  make  any  extension.  But  after  a  time  he  became  sensible, 
and  was  persuaded  to  open  his  mouth.  I  saw  then  that  the  bones 
of  the  palate  were  driven  so  far  back  that  it  was  impossible  to  pass 
my  fingers  behind  them,  as  I  had  intended ;  and  the  extension  could 
be  made  in  no  other  way.  I  extemporized  an  instrument  curved  at 
its  extremity,  which  I  engaged  behind  the  palate,  and,  having  car- 
ried it  a  little  upward,  used  it  to  draw  the  bone  forward,  which  I  did 
without  any  difiiculty ;  but  1  had  hardly  withdrawn  the  instrument 
when  the  fractured  portions  went  back  again.  I  then  contented  my- 
self with  dressing  the  face  with  an  astringent  cerate.  I  likewise 
prescribed  bleeding,  and  some  hours  afterwards  I  had  an  instrument 
better  constructed  to  reduce  the  large  mass  of  displaced  bone  to  its 
proper  position.  I  had  it  held  by  the  child's  hand,  by  that  of  its 
mother  or  of  an  assistant,  each  for  a  certain  time.  Nothing  else  was 
done.  Thus,  by  our  united  attention,  the  tonicity  of  the  parts  was 
maintained,  the  callus  was  developed,  and  in  proportion  as  it  became 
solidified  the  parts  became  stronger,  the  face  assumed  a  good  appear- 
ance,— certainly  better  than  could  have  been  hoped  for  after  such 
marked  displacement, — and  the  child  was  entirely  cured." 

A  cast  in  the  Westminster  Hospital  is  also  alluded  to  of  a  fright- 
ful deformity  produced  by  the  passage  of  a  wagon-wheel  over  the 
face  of  a  man  who  fell  in  the  street.  "  Here  the  bones  were  com- 
pletely shattered,  and  the  maxillae  were  torn  from  one  another,  and 


FBACTUBES   OF  THE  MAXILLARY  BOXES.       513 

death  was  instantaneous."  A  case  is  also  recorded  admitted  into  the 
same  hospital  in  1860,  resulting  from  the  overturning  of  a  cab  upon 
the  face  of  its  occupant,  who  at  the  moment  was  leaning  out  of  the 
window  to  direct  the  driver.  Here,  in  addition  to  a  fracture  of  the 
lower  jaw,  a  little  to  the  left  of  the  median  line,  the  nasal  bones  were 
broken,  both  malars  were  loose  and  separated  from  their  attach- 
ments, and  the  left  bone  was  fractured,  as  also  the  external  angular 
process  of  the  frontal  bone.  Though  not  positively  ascertained,  the 
vomer  was  no  doubt  fractured,  and  probably  the  vertical  plate  of 
the  ethmoid  too.  The  case  is  reported  by  Dr.  Fyfes  in  the  Lancet, 
July  18th,  18(50.  "It  was  remarkable,"  says  this  gentleman,  "to 
observe  how  movable  the  bones  of  the  face  were.  On  watchin*'-  the 
profile  of  the  patient  while  he  was  in  the  act  of  swallowing  food,  the 
whole  of  the  bones  of  the  face  were  observed  to  move  up  and  down 
upon  the  fixed  part  of  the  skull,  as  the  different  parts  were  brought 
into  motion.  It  appeared  as  if  the  integuments  only  retained  them 
in  their  position.  It  was  a  curious  feature  in  the  case,  that  notwith- 
standing the  very  extensive  injury  done,  and  the  violent  character 
of  the  force  which  caused  them,  not  a  single  tooth  was  fractured  or 
misplaced."  This  patient  is  reported  as  having  made  a  perfect  re- 
covery. 

Of  gunshot  injuries  I  have  had  an  opportunity  to  see  some  marked 
examples.  In  comminuted  fractures  it  has  been  my  practice  to 
pick  away  such  pieces  as  were  completely  detached,  but  to  leave 
and  mould,  when  feasible,  all  others  in  place.  I  never  met  with 
trouble  from  uncontrollable  hemorrhage,  and  generally  found  the 
reparative  energy  sufllicient  to  unite  the  comminuted  parts.  In 
Circular  No.  VI.  of  the  Surgeon-General's  Departmc^nt,  however, 
secondary  hemorrhage  is  noted  as  the  principal  source  of  fatality  in 
the  reported  cases:  1579  cases  of  fractures  of  the  facial  bones  are 
reported;  and  of  these  891  recovered,  171  died — the  terminations  of 
517  cases  being  left  still  unaccounted  for. 

The  following  extract,  copied  from  Mr.  Heath's  Essay,  is  from  the 
Official  Medical  and  Surgical  History  of  the  British  Army  in  the 
Crimea  :  "  Wounds  of  the  face,"  says  the  report,  "  though  present- 
ing often  a  frightful  amount  of  deformity,  are  not  generally  of  so 
serious  a  nature  as  their  first  appearance  might  lead  the  uninitiated 
to  expect.  The  reason  for  this,  apart  from  the  fact  that  the  face  con- 
tains no  vital  organ,  seems  obviously  to  be  the  very  free  supply  of 
blood  the  part  receives.  From  this  cause,  the  fleshy  structures  readily 
heal,  and  even  the  bones  are  so  supplied  that  extensive  necrosis 

33 


514  ORAL  DISEASES  AXD  SURGERY. 

rarely  happens.  The  bony  tissues,  also,  are  softer  than  the  long 
bones  of  the  extremities ;  and  we  therefore  here  but  seldom  meet  with 
long  fissures  and  extensive  necrosis  as  a  result  of  concussion  of  bone 
so  often  seen  in  them.  This  leads  us  to  the  very  important  practical 
inference,  not  in  this  situation,  as  a  rule,  to  remove  bony  fragments 
unless  the  comminution  be  great,  or  the  fragments  completely  de- 
tached from  the  soft  parts.  Even  partially  detached  teeth  will  often 
be  found  not  to  have  lost  their  vitality,  and,  if  carefully  readjusted, 
will  become  useful.  There  is,  indeed,  no  great  object,  beyond  per- 
haps the  present  comfort  of  the  patient,  to  be  attained  in  removing 
either  fragments  of  bone  or  loosened  teeth  in  the  great  majority  of 
instances.  If  the}*  die  they  become  loose,  and  are  readily  lifted  away, 
without  trouble  to  the  surgeon,  and  but  little  pain  to  the  patient. 
This  observation  is  especially  applicable  to  fractures  of  the  lower 
jaw.  Surgeons  in  this  war  have  seen  so  many  cases  of  badly  frac- 
tured instances  of  this  kind  unite,  and  that  with  a  very  small  amount 
of  deformity,  that  men  of  experience  are  now  excessively  chary  of 
removing  any  portion  of  this  bone  unless  it  has  become  dead,  or  the 
fragment  is  so  situated  as  to  interfere  considerably  with  the  adjust- 
ment of  the  remainder,  or  the  bone  so  much  comminuted  as  to  give 
no  probable  hope  of  its  becoming  consolidated,  or  so  sharply  angular 
as  to  threaten  further  injury  to  the  soft  parts  or  to  interfere  mate- 
rially with  their  adjustment  and  retention  in  situ.  In  these  fractures 
of  the  lower  jaw,  much  less  support  and  adjustment  than  we  are  in 
the  habit  of  thinking  advantageous  in  ordinary  cases  of  fracture  of  it, 
will  frequently  be  found  necessary,  or  even  admissible.  A  compli- 
cated apparatus  cannot  be  borne  at  first,  on  account  of  the  condition 
of  the  soft  parts,  and  a  slight  support  by  a  gutta-percha  or  Startin's 
wire  splint,  and  a  split  bandage,  is  all  that  can  be  done.  Any 
attempt  at  ligaturing  the  teeth  is  very  generally  not  only  useless, 
but  injm-ious ;  and  it  is  surprising  how  the  parts  often,  as  it  were, 
adjust  themselves,  with  but  little  aid  from  the  surgeon." 

The  treatment  of  a  fractured  jaw  involves  the  indications  to 
be  met,  and  the  mode  or  modes  of  meeting  them.  These  indica- 
tions and  modes  must  of  course  vary  with  almost  every  individual 
case.  For  a  simple  fracture  of  the  inferior  maxillary,  or,  indeed,  as 
well  for  compound  fractures,  the  common  pasteboard  or  gutta-percha 
splint  will  generally  be  found  sufficient  and  reasonably  satisfactory. 
To  make  this  splint,  take  a  piece  of  binder's  board,  or  gutta-percha, 
and  cut  it  as  designated  in  Fig.  93. 

The  board  thus  cut  is  soaked  in  hot  water  until  it  becomes  suf- 


FRACTURES   OF  THE  MAXILLARY  BOXES.        515 

ficiently  softened.  The  fracture  is  then  set,  and  the  splint  moulded 
into  shape  and  position.  To  do  this,  it  is  only  necessary  to  lay  the 
center  of  the  board  beneath  the  chin,  one-half  projecting;  the  wings 
are  now  brought  up  and  moulded  to  the  cheeks ;  next  take  the  pro- 
jecting portion  and  mould  it  around  the  chin  and  sides  of  the  face. 
This  makes  a  complete  cap,  accurately  fitting  the  parts,  and  when 
dry,  is  uniform  and  unyielding.  To  hold  it  in  position,  a  bandage 
must  be  applied;  the  most  simple  is  a  modification  of  Barton's, 
which  suggested  itself  to  me  some  five  or  six  years  back,  and  which  I 
have  since  used  with  much  satisfaction.  The  Barton  bandage,  so  gen- 

-Fia.  93. — Barton's  Bandage. 


A.  Shape  of  the  piece  of  gutta-percha  for  the  chin.    B.  The  same  moulded  to  the  part 
—the  ends,  1, 1,  being  turned  upward,  and  the  sides,  2,  2,  turned  from  before  backward. 

erally  employed  in  fractures  of  the  lower  jaw,  consists  of  a  roller  eight 
yards  in  length  and  from  one  and  a  half  to  two  inches  in  width — 
following  in  this  latter  respect  the  taste  and  idea  of  the  operator.  To 
apply  this  bandage,  place  the  initial  extremity  behind  the  left  ear ; 
carry  it  around  the  side  of  the  head,  over  the  right  parietal  bone; 
cross  to  the  right  over  the  neighborhood  of  the  frouto-parietal  suture; 
carry  down  beneath  the  chin ;  carry  up  on  the  opposite  side ;  cross 
on  the  forehead ;  carry  around  the  left  parietal  bone,  and  meet  the 
beginning  of  the  roller  at  the  occipital  prominence,  or  a  little  below 
it ;  continue  the  turns  until  the  bandage  is  exhausted. 

Gibson's  bandage,  used  in  the  same  and  similar  fractures,  mostly 
employed  when  the  break  occurs  at  the  angle,  consists  of  three  dis- 
tinct turns.  First.  Place  the  initial  extremity  in  front  of  the  car ; 
carry  down  beneath  the  chin;  pass  up  on  opposite  side,  and  meet  the 
initial  by  passing  over  the  fronto-parietal  region  far  enough  back  to 


516  ORAL  DISEASES  AND   SURGERY. 

prevent  slipping ;  repeat  this  turn  three  times.     Second.  Reverse  in 
front  of  and  a  little  above  the  ear,  and  make  three  tm-ns  around  the 

Fia.  94. — Gibson's  Bandage. 


circumference  of  the  vault.  Third.  End  the  third  of  these  last  turns 
at  the  occiput,  and  carry  three  times  around  the  occipito-mental 
circumference.     This  is  also  an  eight-yard  roller. 

The  modification  of  the  Barton  bandage,  which  I  find  to  answer 
every  purpose  in  my  own  practice,  and  which  possesses  the  virtues 
of  ease  in  application,  removal,  loosening  and  tightening,  is  applied 
as  follows:  Take  a  strip  of  roller  material,  one  and  one-half  or  two 
inches  wide,  one  and  one-half  yards  in  length.  Standing  behind 
the  patient,  rest  the  chin  on  the  center  of  this  strip  ;  carry  the  ends 
up,  cross  on  the  forehead,  carry  around  the  sides  of  the  cranium, 
cross  again  at  the  occiput ;  carry  now  forward,  and  tie,  or  otherwise 
fix  in  front  of  the  chin. 

In  the  application  of  this  dressing  or  strip,  if  the  parts  about  the 
jaws  are  tender,  it  is  better  to  make  the  termination  somewhere  on 
the  side  of  the  cranium.  To  efiect  this,  it  is  only  necessary  to  place 
the  chin,  when  first  resting  the  strip,  nearer  to  one  or  the  other  of  its 
ends.     The  character  of  this  bandage  is  shown  in  Fig.  95. 

A  second  method  of  dressing  a  simple  fracture,  one  which  allows 
the  mouth  to  be  partially  open,  consists  in  making  two  plates,  one 
to  fit  the  upper  teeth,  in  part,  and  the  roof  of  the  mouth,  the  other  to 
cap  a  certain  convenient  number  of  the  lower  teeth.  After  setting 
the  fracture,  these  plates  are  put  in  position,  and  attached  to  each 
other  by  means  of  a  piece  of  wax ;  the  attached  plates  are  now  re- 
moved from  the  mouth  and  soldered  together.  This  done,  the  piece 
is  replaced,  and  the  teeth  are  closed  into  the  metal  sockets  ;  the  yard 
bandage  is  next  applied,  and  the  dressing  is  completed.     This  mode 


FBACTURES   OF  THE  MAXILLARY  BONES.       517 

Of  treating  a  fracture  of  the  lower  jaw  I  tbouo-bt  ori-inal  with  my 
self,  but  have  found  it  employed  by  Mr.  Listen,  of  England,  some 

Fig.  95.— The  Yard  Bandage. 


twenty  years  or  more  back,  the  splint  having  been  constructed  by 
Mr.  Nasmyth  at  least  five  years  before  the  idea  suggested  itself  to 
my  mind. 

In  any  ordinary  fracture  of  the  lower  jaw,  the  mode  of  dressing 
described  will  be  found  to  meet  all  indications.  In  complicated  in- 
juries, it  has  been  the  common  experience  that  rules  are  of  little  or 
no  consequence;  the  surgeon  will  find  himself  governed  and  directed 
by  the  peculiarities  of  each  case,  and  will  be  thrown  entirely  upon 
his  own  judgment  and  ingenuity.  Perhaps  no  better  exemplification 
of  this  fact  exists  than  was  exhibited  in  the  practice  of  Dr.  T.  B. 
Gunning,  of  New  York,  in  the  case  of  Secretary  Seward.  The  ideas 
of  Dr.  Gunning  are  multitudinous  in  this  direction;  and  while  his 
professional  sense  has  prompted  him  to  the  fullest  exhil)it  of  every 
means  he  has  employed,  yet  I  am  well  satisfied,  from  what  I  know 
of  the  profession  at  large,  that  the  arrangements  are  too  complex  to 
come  into  general  use.  The  monograph  published  by  this  gentle- 
man should,  however,  be  in  the  hands  of  every  surgeon.  I  know  of 
no  one  who  seems  to  have  studied  the  subject  with  more  care  or 
wh5  has  brought  to  it  a  more  practiced  and  matured  judgment. 

Fig.  96  represents  the  inner  surface  of  a  very  simple  splint  used 
by  Dr.  G.,  which  incloses  all  the  teeth  and  part  of  the  gum  of  the 
low-er  jaw.  This  splint,  as  will  be  seen,  would  be  very  applicable 
where  there  were  teeth  on  either  side  of  the  fracture,  where  there 


518 


ORAL  DISEASES  AND  SURGERY. 


was  little  tendency  to  vertical  displacement,  and  where  there  was  an 
absence  of  swelling  and  undue  tenderness.    The  holes  marked  A  are 

Fig.  96. — One  of  Dr.  Gunning's  Splints. 


for  purposes  of  cleanliness,  being  large  enough  to  receive  the  point 
of  a  syringe-nozzle.  When  in  position,  the  jaws  are  to  be  closed, 
the  plate  simply  resting  against  the  upper  jaw  or  teeth ;  the  strip 
bandage,  as  described,  may  be  thrown  around  the  jaw  and  head. 
Dr.  Gunning  uses  this  splint  without  fastenings,  but  not  unfrequently 
finds  it  necessary  to  secure  it  in  place  by  ligatures,  and  in  some 
instances  by  screws,  which  are  made  to  pass  into  or  between  the 
teeth.  In  cases  of  much  tendency  to  displacement.  Dr.  Gunning  uses 
a  splint  very  much  like  the  one  which  had  previously  suggested 
itself  to  Mr.  Nasmyth  and  afterward  to  myself, — not  so  good  or 
convenient,  however,  I  am  compelled  to  think,  as  it  unnecessarily 
covers  too  many  teeth,  and  is  thus  made  cumbersome.  This  second 
splint  is  shown  in  Fig.  97. 

Fig.  97. — Dr.  Gunning's  Second  Splint. 


To  secure  this  splint  in  place,  screws  are  used.  C  represents  an 
opening  left  between  the  conjoined  splints,  for  food,  speech,  etc.;  D, 
a  channel  for  the  saliva  from  the  parotid  gland  to  enter  the  mouth. 
E  is  a  screw  used  in  the  retention  of  the  piece. 


FRACTURES  OF  THE  MAXILLARY  BOXES. 


519 


The  third  modification  of  Dr.  Gunning  consists  in  the  attachment 
to  his  splint  of  wings  of  steel.    This  is  used  in  cases  where  the  teeth 

Fig.  98.— Dr.  Gunxixg's  Third  Splixt. 


have  been  lost  in  either  jaw.  F,  upper  wing;  G,  lower  wing;  H, 
mental  band,  to  hold  the  jaw  up  in  the  splint ;  I,  neck-strap,  to  keep 
the  band  back ;  K,  balance-strap,  to  hold  the  cap  in  place. 


Fig.  99. — Dr.  Guxning's  Fourth  Splint. 


This  is  a  splint  devised  by  Dr.  Gunning  to  answer  general  case.-'. 
He  suggests,  first,  the  moulding  of  six  or  eight  size.-^,  to  be  kept  ready 
for  use,  from  which  one  is  to  be  selected  suitable  for  any  particular 
case  presenting.  The  wings  are  of  malleable  iron,  tinned  to  prevent 
rusting,  and  for  more  ready  soldering.  These  sizes,  he  thinks,  would 
be  sufficient  to  select  from.  The  splint  should  have  a  handle  in 
front,  that  it  may  be  used  as  a  cup  to  take  the  impression  of  the 


520  ORAL   DISEASES  AND   SURGERY. 

jaw,  the  holes  being  useful  to  allow  a  small  probe  to  be  passed 
thi'ough  the  wax  down  to  the  teeth,  thus  allowing  air  to  enter  to 
facilitate  the  removal  of  the  in)pression,  and,  when  in  use  as  a  splint, 
giving  entrance  to  warm  water,  thrown  from  a  syringe,  to  keep  the 
parts  clean. 

The  splint  should  be  made  to  fit  well  by  bending,  cutting  off  the 
edges,  and  rounding  them  up  smooth.  When  a  tooth  projects  so  as 
to  keep  the  splint  from  fitting,  a  hole  may  be  cut  to  let  it  through,  if 
the  metal  cannot  be  hammered  out.  This  should  all  be  done  before 
taking  the  impression,  as  a  well-fitted  cup  assists  greatly  in  this  im- 
portant matter. 

A  splint  devised  by  Dr.  Bean,  of  Georgia,  used  with  decided  suc- 
cess during  the  war  of  the  rebellion,  among  the  Confederate  troops, 
is  in  its  character  similar  in  principle  to  that  of  Dr.  Gunning.  The 
interdental  portion  is  almost  precisely  the  same.  A  modification 
consists  in  the  use  of  a  mental  compress.  This  is  simply  a  "piece 
of  light  wood,  four  and  a  half  inches  in  length,  three-sixteenths  of 
an  inch  in  thickness,  and  one  inch  and  a  half  in  width  in  the  middle, 
tapering  to  seven-eighths  of  an  inch,  and  round  at  the  ends,  to  each 
of  w^hich  is  attached  a  metallic  side  piece,  four  or  five  inches  in 
length  and  from  three-quarters  to  one  inch  in  width,  also  a  shallow 
cup,  fitting  the  apex  of  the  chin.  Incasing  these  side  pieces  are 
temporal  straps,  made  of  stout  cloth,  and  secured  by  a  strong  cord 
at  the  base  of  each  piece. 

"A  bandage,  occipito-frontal,  is  composed  of  a  band  passing  around 
the  head,  from  the  forehead  to  the  occipital  protuberance,  and  se- 
cured by  a  buckle,  one  inch  to  the  right  of  the  median  line  behind, 
of  another  strap  secured  to  the  band  in  front  and  behind,  and  a  third, 
extending  from  the  temporal  buckles  on  either  side  and  secured  to 
the  middle  strap  at  the  point  of  crossing." 

It  is  sometimes  the  case  that  from  comminution,  or  other  causes, 
fractures  of  the  inferior  maxilla,  like  fractures  of  other  bones,  fail 
to  unite.  Necrosis,  intervening,  frequently  prevents  such  union. 
To  treat  these  cases,  the  practitioner  will  find  each  to  have  its  spe- 
cial indications.  If  necrosis  exists,  the  exfoliation  of  the  sequestrum 
must  be  awaited.  In  the  few  cases  where  the  vital  forces  seem  at 
fault,  they  are  to  be  stimulated  and  elevated.  If  it  occurs  that  the 
ends  of  the  fragments  have  become  rounded,  and  perhaps  tipped  with 
cartilage,  operative  means  must  of  necessity  be  resorted  to, — such 
means  varying  with  the  circumstances.     One  plan,  much  approved, 


FRACTUBES   OF  THE  MAXILLARY  BONES.       521 

is  to  pass  through  the  parts  a  scton,  composed  of  several  strands  of 
wire,  to  be  removed  strand  by  strand,  as  inflammation  is  to  be  mod- 
ified. Or,  in  place  of  the  wire,  other  material  may  be  used,  as  silk, 
thread,  tape,  etc.  Another  operation  consists  in  boring  one  or  more 
holes  through  each  of  the  fragments,  and  tying  them  together  with 
sutures  of  wire.  Resecting  the  ends  is  still  another  means  success- 
fully employed  by  many.  Irritating  the  ends,  and  thus  provoking 
the  desired  inflammatory  action,  by  rubbing  the  fragments  together, 
is  still  another  plan. 

Attention  to  the  circumstances  of  a  patient  sufi'ering  from  ununited 
fracture  is  important.  A  case  exhibited  several  years  back,  at  the 
clinic  of  the  University  of  Pennsylvania,  l)y  Professor  Henry  II. 
Smith,  was  plainly  enough  due  to  the  individual  having  confined 
himself  exclusively  to  a  diet  of  potatoes,  such  diet,  in  this  case  at 
least,  being  insufficient  to  accomplish  the  repair.  The  case  of  Mr. 
Seward  comes,  in  many  respects,  within  the  category  of  the  un- 
uniting  fractures,  the  means  to  overcome  which  constituted  the  skill 
employed,  the  causes  here  being  necrosis  and  non-fixedness. 

Complications,  whatever  their  character,  are  to  be  treated  on 
general  principles.  It  is  impossible  to  direct  any  special  course, 
because  of  such  conditions  being  constant  to  no  rule.  Hemorrhages, 
so  frequently  alluded  to,  I  have  never  met  with  of  any  particular  mo- 
ment. When  they  do  occur,  however,  they  are  nearly  always  second- 
ary in  character,  and  it  maybe  well,  where  possible,  to  treat  them  in 
anticipation  :  for  example,  an  injury  which  has  lacerated  the  facial 
artery  would  perhaps  yield  little  or  no  hemorrhage  at  the  time  of 
accident ;  yet,  as  the  process  of  sloughing  should  expose  the  sound 
part  of  the  vessel,  hemorrhage  might  be  profuse  and  alarming 
enough.  In  these  and  corresponding  cases,  circumstances  might, 
in  special  instances,  justify  one  in  searching  for  the  ends  of  the  ves- 
sels and  ligating  them.  Injuries  to  the  teeth  are  to  receive  due 
attention :  it  is  not  by  any  means  every  loosened  tooth  that  is  to 
be  removed,  or  every  displaced  one  that  is  to  be  looked  on  as  lost 
to  usefulness.  Fractures  occurring  about  the  neck  of  the  inferior  jaw 
are  to  have  the  displacements  corrected  by  the  application  of  such 
compresses  as  are  found  to  answer  the  purpose,  no  matter  how  closely 
such  applications  follow  any  special  rules,  or  how  far  they  depart 
from  them.  I  do  not  remember  in  the  course  of  my  professional  life 
ever  having  treated  two  fractures  precisely  alike. 

In  fractures  of  the  superior  jaw,  complications  are  still  more 
anomalous.     Thus,  I  remember  being  compelled  in  one  case  to  re- 


522  ORAL   DISEASES  AND  SURG  ERF. 

move  the  whole  alveolar  process  of  both  superior  maxillas,  the  result 
of  a  kick  received  from  a  mule.  In  this  case  the  patient  was  a 
man  broken  down  by  drink  and  dissipation.  I  anticipated  by- 
compulsion  a  process  which  I  felt  sure  would  have  resulted,  but 
which,  to  have  been  accomplished  per  vias  naturales,  would  have 
cost  the  patient  weeks  of  sufifering,  and,  not  unlikely,  life.  I  have 
seen  a  case  of  fracture  of  the  right  upper  maxilla,  where  the  alve- 
olar process  (the  fractured  part)  hung  at  least  a  quarter  of  an  inch 
below  the  common  level.  In  this  case  the  part  was  moulded  back 
into  its  place  and  supported  by  a  simple  strip  passing  across  the 
jaw  and  fixed  a  little  beyond  the  fronto-parietal  suture.  In  three 
days  the  part  became  self-supporting,  and  in  two  weeks  the  patient 
was  eating  solid  food. 

Gunshot  injuries  of  the  face  and  jaw  are  of  every  conceivable 
variety.  The  surgeon  does  primarily,  in  such  cases,  all  that  he  can, 
and  rests  his  hopes  on  nature. 

With  Hamilton,  we  have  to  remark  that  it  is  "  impossible  to  dis- 
cuss in  detail  all  the  varieties  of  accidents  to  which  the  complicated 
structures  of  the  face  are  exposed  from  balls  or  other  missiles." 

Certain  general  rules  are,  however,  to  be  observed :  for  instance, 
as  suggested  by  this  surgeon,  "  Missiles  entering  and  lodging  in  the 
face  ought  to  be  extracted  as  speedily  as  possible ;  and,  whenever 
it  is  practicable,  they  should  be  removed  through  the  mouth.  If 
permitted  to  remain,  they  expose  to  the  danger  of  secondary  hemor- 
rhage, and  increase  the  chance  of  subsequent  disfigurement. 

"  Loose  fragments  of  bone  should  be  speedily  replaced,  unless 
very  much  detached  from  the  flesh  and  periosteum,  experience 
having  proven  that  they  unite  in  most  cases  with  facility. 

"  No  piece  of  skin  which  is  torn  up  should  ever  be  removed  unless 
it  is  absolutely  dead ;  but  it  should  be  laid  back  carefully  in  place, 
and  retained  either  by  a  few  delicate  sutures  or  by  some  other  gentle 
means  of  support.  Tight  ligatures  and  firm  straps  of  adhesive  plaster 
are  apt  to  bind  the  tissues  and  destroy  their  little  remaining  vitality. 
The  best  means  of  supporting  a  fragment  of  skin  in  place,  in  many 
cases,  is  to  lay  upon  it  a  thin  piece  of  lint  smeared  with  cerate,  and 
over  this  a  pledget  of  cotton-batting,  securing  the  whole  with  adhe- 
sive plaster  or  a  roller. 

"As  soon  as  the  inflammation  and  consequent  induration  have 
completely  disappeared,  and  not  before,  it  will  be  proper  to  make 
the  final  anaplastic  operations." 

An  addendum  to  these  suggestions  of  Dr.  Hamilton  is  to  be  made 


FRACTURES  OF   THE  MAXILLARY  BOXES.        523 

by  directing  attention  to  the  necessity  of  controlling  and  combating 
inflammation.  To  this  end  cold  water  is  to  be  freely  used  locally^ 
saturated  cloths  being  renewed  as  the  temperature  is  elevated; 
or  the  water  may  have  to  be  medicated,  lead  and  laudanum  gen- 
erally being  added.  A  very  admirable  antiphlogistic  application  is 
prepared  by  adding  to  §xvi  of  water  5ij  of  the  former  and  .^ij  of  the 
latter.  If  a  patient  should  be  robust  and  plethoric,  it  will  in  most 
cases  be  advisable  to  assist  the  local  treatment  by  cathartics, — mag. 
sulph.  or  the  ordinary  Seidlitz  powder  being  employed. 


CHAPTER    XXXIV. 

DISLOCATION   OF   THE   INFERIOR   MAXILLA. 

The  frequency  of  this  accident,  the  terror  which  it  excites,  and  the 
harm  resulting  when  not  properly  cared  for,  lend  to  it  an  impor- 
tance which  renders  a  careful  appreciation  of  it  a  matter  of  much 
concern. 

There  are  four  forms  of  submaxillary  displacement :  complete  dis- 
location, incomplete,  bilateral,  unilateral.  In  the  first  of  these,  one 
or  both  condyloid  processes  have  slipped  fully  out  of  the  articulating 
fossae  and  rest  entirely  in  front  of  the  articulating  eminence,  as  ex- 
hibited in  the  view. 

Fig.  100. — Complete  Dislocation  of  Jaw. 


>- 


In  the  second,  the  condyle  rests  upon  the  inter-fibro  cartilage, 
directly  over  the  articulating  eminence,  and  will  remain  fixed,  or 
may  fall  backward  or  forward  as  directed  by  accident,  not  being 
retained  in  its  position,  as  is  frequently  thought,  by  the  coronoid 
process  being  hooked  under  the  malar  bones,  but  resting,  as  it  were, 
upon  a  point,  with  complete  balance  in  the  muscular  structures. 

A  bilateral  luxation  is  a  displacement  of  both  condyles,  and  is 
of  somewhat  more  frequent  occurrence  than  the  unilateral,  or  dis- 
placement of  one  side. 
(524) 


DISLOCATION  OF  THE  INFERIOR  MAXILLA.      505 

The  diagnosis  of  a  luxation  is  an  exceedingly  simple  matter.  An 
open  mouth,  with  inability  to  close  it,  the  lower  jaw  thrust  forward 
in  a  straight  line,  or  turned  to  the  right  or  left,  according  to  the  acci- 
dent, indicates  a  luxation  of  a  bilateral  or  unilateral  character. 

The  exciting  causes  of  dislocation  are  various :  yawning,  vomit- 
ing, putting  large  bodies  into  the  mouth;  blows  received  upon  the 
chin  from  above  downward,  or  in  front,  while  the  mouth  is  open ; 
the  extracting  of  teeth,  or  extending  the  jaws  widely  for  the  conven- 
ient filling  of  them.  The  first  case  I  ever  met  with  occurred  to  a 
middle-aged  man  while  immoderately  laughing. 

The  predisposing  cause  of  the  accident  resides  in  a  general  or 
special  laxity  of  the  articulations :  thus,  all  are  acquainted  witli  per- 
sons who  without  effort  will  dislocate  a  finger  or  a  toe.  I  have  met 
with  cases  where  the  operation  of  removing  a  tooth  was  always 
attended  with  unilateral  luxation  unless  a  mento-occipital  sling  was 
used. 

What  is  the  condition  of  the  parts  in  luxation  ?  By  placing  the 
finger  immediately  in  front  of  the  tragus  of  the  ear  when  the  mouth 
is  closed,  and  carrying  it  forward  along  the  zygoma,  the  surface  is 
found  to  be  a  plane.  If  the  finger  is  kept  on  the  surface,  and  the 
mouth  opened,  it  is  felt  to  drop  into  a  fossa.  This  fossa  is  the  glen- 
oid ;  the  concave  rim  above  is  the  border  of  the  cavity ;  the  rounded 
prominence  below  is  the  condyle  of  the  lower  jaw.  Placing  the  jaw 
of  the  cadaver  in  this  position,  and  dissecting  down  to  the  articulation, 
the  condyle  is  found  slipped  forward,  resting  upon  the  intorarticular 
fibro-cartilage, — the  fossa  has  been  partially  vacated,  and  the  bone 
rests  against  the  articulating  eminence.  If  now  the  condyle  is  dragged 
downward  and  forward  over  the  eminence,  the  glenoid  cavity  will  be 
found  completely  vacated,  and,  unless  by  manipulation,  the  condyle 
cannot  be  restored  ;  laying  now  back  the  soft  parts,  the  cavity  in 
fi-ont  of  the  tragus  will  be  found  greatly  increased,  the  finger  falling 
into  the  unoccupied  fossa.  (An  added  diagnostic  sign  is  then  found 
to  be  increa.sed  depth  and  size  of  the  fossa  in  front  of  the  ear:  this  it 
is  desirable  to  remember,  as  a  fracture  of  the  neck  might  simulate  a 
luxation.)  Returning  to  the  examination,  we  find  that  to  reduce 
this  dislocation  it  is  necessary  to  depress  the  head  of  the  bone  below 
the  level  of  the  articulating  eminence,  which,  now  being  back  of  the 
condyle,  serves  to  fix  it  in  its  abnormal  position,  as  originally  it 
was  the  means  of  its  retention  in  place.  But  we  pass  to  the  con- 
sideration of  the  associate  parts :  the  capsular  ligament  we  do  not 
find  torn,  as  a  rule,  but  stretched  and  elongated ;  the  lateral  ligar 


526  ORAL   DISEASES  AXD  SUEGERr. 

mcnts  do  not  seem  particularly  interfered  with,  and  impress  us  as 
having  little  influence  in  the  matter,  one  way  or  another ;  the  tem- 
poral muscle  shows  itself  stretched  and  dragged  forward,  but  is 
seldom  torn ;  the  pterygoid  and  masseter  are  relaxed. 

Dislocation  is  of  more  frequent  occurrence  in  women  than  in  men, 
is  uncommon  in  children,  and  rare  in  the  robust.  When  a  disloca- 
tion has  existed  for  a  long  time,  there  seems  a  tendency  on  the  part 
of  nature  to  make  some  compromise  with  the  condition ;  the  jaw 
will  gradually  recover  considerable  of  the  lost  motion,  and  I  have 
seen  cases  where  it  seemed  the  patient  masticated  his  food  without 
the  least  trouble.  The  original  contour  of  the  face  I  have  never, 
however,  seen  entirely  restored. 

A  luxation  of  the  lower  jaw,  like  the  luxation  of  any  other  l^one,  if 
left  unreduced,  even  for  a  very  few  days,  will  be  found  difficult  to 
replace ;  the  muscles  become  contracted,  the  condyle  settles  itself  in 
its  new  position,  lymph  is  effused  and  coagulates,  and  the  general 
aspect  and  relations  of  the  joint  are  changed.  A  patient,  however,  so 
situated  is  not,  as  remarked  by  Dr.  Gross,  to  be  left  unassisted,  or 
to  the  relief  afforded  by  nature.  In  his  System  of  Surgery,  this  gen- 
tleman relates  a  case  in  which  a  Mr.  Donovan,  an  Irish  surgeon, 
effected  reduction  ninety-eight  days  after  the  occurrence  of  the  acci- 
dent. Where  ordinary  means  fail.  Dr.  Gross  recommends  that  the 
efforts  at  reduction  be  aided  by  the  subcutaneous  section  of  any 
muscles  implicated. 

Suliluxations  are  of  very  common  occurrence,  particularly  among 
weak  women  of  easy  means  and  luxurious  lives.  In  England,  at- 
tention was  first  directed  to  the  condition  by  Sir  Astley  Cooper ;  in 
this  country  it  certainl}^  has  needed  no  particular  one  to  discuss  it, — a 
proof,  perhaps,  of  the  physical  superiority  of  English  over  American 
ladies.  This  condition  depends,  evidently  enough,  upon  a  laxity 
of  the  ligaments,  and  perhaps  more  particularly  on  the  weakness  of 
the  muscles  of  the  part.  In  yawning,  or  not  unfrequcutly  in  ordi- 
nary mastication,  the  condyle  will  slip  forward  on  the  articulating 
eminence,  and,  for  a  moment,  the  mouth  cannot  be  closed,  requiring, 
in  many  cases,  the  assistance  of  the  hand  to  effect  it.  Depending  on 
weakness,  a  permanent  cure  is  only  to  be  looked  for  as  a  higher  and 
stancher  vitality  is  secured.  Thus,  such  a  tendency  and  condition 
are  to  be  treated  by  cold  bathing,  tonic  medication,  exercise,  etc. 
In  the  case  of  a  lady  liable  to  such  luxation,  and  who  Avas  made 
very  nervous  by  its  occurrence,  the  accident  was  entirely  guarded 
against  by  the  patient  wearing  the  occipito-mental  caps  and  bands. 


DISLOCATION  OF  THE  INFERIOR  MAXILLA.     507 

I  was  once  consulted  by  a  lady  who  was  awakened  almost  every 
night  by  the  peculiar  and  unbearable  pain  attendant  on  such  slip- 
ping of  the  condyle  during  the  relaxation  of  sleep. 

Dislocations  associated  with  fracture  are,  happily,  of  very  rare  oc- 
currence. I  myself  have  never  seen  a  case,  unless,  indeed,  "it  existed 
in  association  with  certain  gunshot  wounds,  when  an  appreciation  of 
the  condition,  if  existing,  would  have  been  of  very  little  moment. 
Delamotte  records  a  case  where,  in  the  person  of  a  girl,  double 
luxation  existed  with  fracture  of  the  body  of  the  bone.  Another  is 
recorded  by  Roberts,  where  the  body  was  broken  in  front  of  the 
right  ramus,  and  the  condjde  dislocated  outward.  A  third  case 
(Heath)  is  reported  in  the  Dublin  Medical  Gazette,  and  "  occm-red 
in  a  boy  of  eight,  who  suffered  a  fracture  at  the  symphysis,  with 
dislocation  of  the  left  condyle  upward  and  backward.  There  was 
bleeding  from  the  ear,  and  the  chin  was  much  retracted  and  turned 
to  the  left ;  the  mouth  was  open,  but  could  be  closed,  and  it  was  then 
observed  that  the  lower  molars  overlapped  the  upper,  but  that  the 
lower  incisors  were  at  least  one  inch  behind  the  upper.  Reduction 
was  easily  effected,  and  the  case  did  well." 

Luxations  are  sometimes  congenital.  The  first  case  of  this  kind 
was  noticed  by  Mr.  Robert  Smith,  of  Dublin,  who  gives  with  mi- 
nuteness the  results  of  his  dissection.  The  patient,  an  idiot  from  in- 
fancy, died  at  the  age  of  thirty-eight.  The  luxation  existed  on  the 
right  side,  which  was  remarkably  deformed,  having  a  singularly  hol- 
low appearance,  which  strikingly  contrasted  with  that  of  the  sound 
one,  which  was  unusually  full  and  plump.  The  extremity  of  the 
finger  could  be  readily  pressed  between  the  posterior  margin  of  the 
jaw  and  the  auditory  canal,  owing,  as  was  found  on  dissection,  to 
the  absence  of  the  condyle  of  the  bone,  which  was,  in  fact,  greatly 
atrophied  nearly  as  far  forward  as  the  symphysis.  There  was  no 
interarticular  cartilage  or  distinct  capsular  ligament,  and  the  mas- 
seter,  pterygoid,  and  temporal  muscles  were  much  wasted.  The 
temporal,  malar,  superior  maxillary,  and  sphenoid  bones  were  im- 
perfectly developed,  and  the  glenoid  cavity  existed  merely  in  a  rudi- 
mentary state. 

Treatment  o/iu^a^fo??.— By  referring  back  to  Fig.  100,  it  will  be 
plainly  evident  that  the  reduction  of  a  disarticulated  condyle  con- 
sists in  getting  it  back  of  the  emineutia  articularis.  How  best  to  do 
this  is  the  question. 

1st.  Wrap  the  thumb  in  delicate  napkins,  seat  the  patient  on  a 
strong  chair,  and,  standing  behind  him,  rest  his  head  against  your 


528  ORAL  DISEASES  AND  SURGERY. 

person ;  place  now  the  protected  thumbs  upon  his  inferior  molar 
teeth,  and  with  main  strength  force  the  jaw  directly  downward  and 
a  little  backward :  the  moment  you  have  depressed  the  articulating 
face  of  the  condyle,  it  will  be  felt  to  be  dragged  into  place.  The 
question  of  the  force  required  to  depress  the  condyle  is  the  question 
of  the  muscular  tone  of  the  individual.  In  some  cases  the  reduction 
is  efifected  almost  before  you  are  aware  of  having  exerted  any  press- 
ure ;  in  others  it  cannot  be  secured  without  the  assistance  of  mechan- 
ical appliances. 

Fig.  101. 


2d.  Failing  to  reduce  a  luxation  standing  behind  a  patient,  reverse 
the  position,  resting  the  head  against  an  assistant. 

3d.  Take  corks,  one  or  two,  according  as  the  luxation  is  single  or 
double,  force  them  between  the  wisdom  teeth  of  upper  and  lower 
jaws  as  firmly  and  fixedly  as  possible;  now  gradually  force  the  chin 
forward  and  upward,  using  either  the  hands,  or  a  tourniquet  applied 
around  the  head. 

4th.  Take  a  piece  of  wood  about  a  foot  in  length,  place  one  end 
upon  the  molar  teeth  of  the  luxated  side,  make  a  fulcrum  of  the 
molar  teeth  of  the  upper  jaw  of  the  opposite  side,  and  elevate  the 
end  held  in  the  hand.  If  the  luxation  is  double,  reduce  one  side  at 
a  time.  In  the  use  of  this  lever,  I  have  secured  the  result  more  easily 
by  resting  the  center  of  the  piece  of  wood  upon  the  molar  teeth  of 
the  side  to  be  reduced,  carrying  the  end  downward.  I  think  it  will 
be  found  the  most  satisfactory  application  of  the  power. 

The  forceps  invented  by  Stromeyer  yields  a  powerful  leverage. 
This  consists  of  two  blades  so  expanded  at  the  extremities  as  to  fit, 


DISLOCATION  OF  THE  INFERIOR  MAXILLA. 


529 


as  well  as  may  be,  the  dental  arches,  these  blades  being  covered 
with  leather;  a  spring  between  the  handles  throws  them  apart, 
thus  closing  the  blades.  Reduction  is  attempted  in  two  ways.  Intro- 
ducing the  padded  blades  so  that  each  shall  rest  upon  its  proper  tooth 
or  teeth, — the  third  and  second  molars, — the  handles  are  grasped 
in  the  hands  of  the  operator  and  gradually  brought  together;  when 
thus  the  blades  have  been  so  separated  that  it  is  inferred  that  the 
face  of  the  condyle  is  below  the  level  of  the  obstructing  eminence, 
the  jaw  is  to  be  pushed  forcibly  backward  into  its  place  by  an 
assistant. 

Another  method  of  using  this  instrument  is  the  employment  of 
a  screw  and  nut  which  passes  between  the  blades ;  a  delicate 
wrench  fits  this  nut,  and  through  its  instrumentality  the  han- 
dles are  gradually  screwed  together,  separating  of  course  the  blades. 
The  manipulation  of  pushing  back  the  jaw,  Stromcyer,  however, 
suggests,  should  be  effected  at  the  same  moment  with  the  sudden 
closing  of  the  blades. 

Fig.  102.— Yertico-Mental  Sling  or  Cap. 


5th.  Ansesthesia —li^  recent  cases  the  anjesthctic  agents  may  not 
be  required,  although  there  is  seldom  objection  to  their  employment. 
In  cases,  however,  of  any  standing,  or  in  muscular  persons,  it  often 

34 


530  ORAL  DISEASES  AND  SURGERY. 

happens  that  it  is  impossible  to  succeed  in  the  reduction  without 
the  aid  of  relaxating  agents;  while  again,  the  formation  of  adhe- 
sions will  be  found  to  make  attempts  at  reduction  both  painful  and 
formidable. 

A  luxation  having  been  reduced,  it  becomes  necessary  to  give 
support  to  the  parts,  and  insure  against  the  possibility  of  the  mouth 
being  too  widely  oj^cned.  This  is  most  comfortably  insured  by  a  ver- 
tico-mental  sling  made  of  elastic  straps. 


CHAPTER    XXX Y. 

OPERATIONS   UPON   THE    LIPS   AND   CHEEK. 

Hare-lip. — This  defect  consists  iu  a  break,  single  or  doul)le,  in 
tbe  continuity  of  the  lip.  The  deficiency  is  almost  precisely  similar 
to  that  which  exists  naturally  in  the  hare  and  rabbit,  from  which 
the  imperfection  gets  its  name.  When  congenital,  it  is  always 
found  associated  with  the  superior  lip. 

A  general  view  of  the  operation  for  the  relief  of  hare-lip,  and  in- 
deed the  view  which  comprises  or  embraces  the  principles  of  the 
cure,  is,  that  the  margins  of  the  cleft  or  break  are  to  be  pared, 
brought  together,  and  held  in  apposition  until  nature  shall  secure 
a  union.  There  are,  however,  nice  surgico-mechanical  associations, 
which  are  to  be  studied  in  connection  with  such  principles  of  oper- 
ation. Cutting  manipulations  upon  the  face,  and  especially  about 
the  lips,  claim,  it  seems  to  me,  more  than  ordinary  skill  and  judg- 
ment. Such  skill  and  judgment  the  surgeon  should  be  prepared  to 
exercise,  if  not  for  humanity's  sake,  at  least  for  his  own  credit  and 
reputation ;  for,  as  truly  remarked  by  Mr.  Skey,  "  on  the  more  or 
less  perfect  result  of  such  operations  depend  the  appearance  and 
expression  of  the  patient  for  life."  And  surely,  just  so  far  as  the 
surgeon  shall  beautify  or  mar,  is  the  comfort  of  the  patient,  as  well 
as  his  own  reputation,  influenced. 

A  proper  and  comprehensive  study  of  hare-lip  divides  itself 
naturally  into  three  subjects  of  special  signification  : 

1st.  The  time  of  life  best  suited  to  the  operation. 

2d.  The  condition  of  the  patient. 

3d.  The  mode  of  operating. 

"I  advise  you,"  says  Mr.  Liston,  "to  defer  the  operation  till  the 
first  set  of  teeth  come  in,  and  I  have  seen  good  reasons  for  adhering 
to  such  rule.  When  tbe  operation  is  undertaken  at  an  early  period, 
there  is  often  great  diEBculty ;  sometimes  union  does  not  take  place, 
the  parts  turn  out  again,  and  the  patient  is  rendered  more  deformed 
than  in  the  first  instance.  When  the  features  are  enlarged  some- 
what, you  have  more  ground  to  work  upon,  you  can  put  the  parts 
•^  (531) 


532  ORAL  DISEASES  AXD   SURGERY. 

then  neatly  together,  and  you  can  almost  answer  positively  for  the 
union  taking  place.  I  operated,"  continues  this  gentleman,  "  on  a 
child,  the  other  day,  in  whom  the  operation  had  been  performed 
twelve  months  ago.  The  parents  were  anxious  to  have  it  per- 
formed, but  I  then  refused  ;  it  was  done,  however ;  but  the  moment 
the  pins  were  removed,  the  lip  turned  out  as  before." 

"  For  my  own  part,"  says  Mr.  Bransby  Cooper,  "  I  entirely  agree 
with  Sir  Astley  Cooper,  in  regarding  it  as  unsafe  to  operate  on 
infants  before  weaning:  first,  because,  from  their  excessive  irrita- 
bility, they  are  totally  unable  to  sustain  any  loss  of  blood ;  and 
.■secondly,  because,  after  the  operation,  they  are  rendered  incapable  of 
sucking  ;  and,  indeed,  Sir  Astley  has  pointed  out,  in  his  lectures, 
the  frequency  of  the  failures  he  met  with  in  his  own  practice,  in 
operating  upon  infants  shortly  after  birth.  I  consider  the  best  time, 
under  ordinary  circumstances,  to  be  soon  after  the  child  is  weaned, 
as  it  is  then  capable  of  receiving  nourishment  independently  of  its 
mother,  and  has  overcome  the  distress  incidental  to  the  separation 
from  her." 

Dr.  Houston,  of  London,  in  examining  the  question  as  to  the 
period  of  life  best  fitted  for  the  performance  of  the  operation,  decides 
in  favor  of  the  third  month  after  birth ;  urging,  as  his  reasons,  that 
the  parts  recover  themselves  better  than  when  the  operation  is  per- 
formed later  in  life ;  that  the  lip,  in  due  time,  acquires  fullness  and 
pliancy;  the  nose  is  prevented  from  assuming  a  spread-out,  ugly 
appearance;  the  fissure  in  the  palate,  if  there  be  any,  closes  greatly 
with  the  growth,  if  supported  by  a  firm  and  perfect  lip;  bad  habits 
of  speaking,  such  as  guttural  or  nasal  utterance,  which  if  once  estab- 
lished become  irremediable,  are  avoided ;  and,  by  removing  the  dis- 
figuration before  the  child  is  conscious  of  its  existence,  it  is  spared 
the  feelings  of  humiliation  which  the  consciousness  of  such  an  in- 
firmity necessarily  imparts,  and  which  invariably  gives  a  tone  to  the 
character  of  the  individual.  He  states  that  he  has  operated  on 
several  infants  three  months  old,  with  equal  success  in  all  cases, 
and  has  never  failed. 

Dupuytren  recommends  the  third  month;  Vclpoau,  the  first  six; 
but  if  that  be  already  passed,  he  defers  operating  until  the  tenth  or 
fifteenth  year. 

Skey,  differing  from  Yelpeau,  says,  "  The  operation  may  be  per- 
formed at  almost  any  age,  but  should  not  be  undertaken  under  about 
six  months." 

"  The  period  of  life,"  says  Mr.  Fergusson,  "  which  I  think  very 


OPERATIONS    UPON  THE  LIPS  AXD    CHEEK.      ^.33 

eligible  for  these  operations,  is  either  liefore  the  teeth  begin  to  show 
through  the  gums,  or  shortly  after  the  child  has  ceased  to  suck,  pro- 
vided the  health  seems  good.  If  the  patient  is  allowed  to  grow  up. 
he  is  usually  unmanageable  until  after  the  age  of  pul)crty ;  but,  if 
possible,  the  malformation  should  always  be  put  right  before  this 
time,  as  there  is  a  better  chance  of  the  gum  and  nose  assuming  a 
good  shape  than  after  they  have  arrived  at  their  full  development. 
Indeed,"  continues  Mr.  Fergusson,  "there  are  so  many  advantages 
besides  these — as  to  speaking,  appearance,  etc.— that  it  is  wonder- 
derful  any  surgeon  can  recommend  delay  in  such  cases  after  the 
first  or  second  year  of  life.  I  have  myself,"  says  Mr.  Fergusson. 
"  operated  frequently  within  the  first  three  months,  and  in  some  of 
these  instances  seen  the  child  take  the  breast  readily,  Avith  the  pins 
still  in  the  lip." 

Dr.  J.  Mason  Warren  has  operated  on  infants  only  a  few  days 
old,  with  perfect  success.  Professor  P.  Dubois  read  before  the 
Academy  of  Medicine  of  Paris  a  paper  on  this  subject,  and  referred 
to  seven  instances  which  had  come  under  his  notice,  where  the  pro- 
ceedings had  been  resorted  to,  and  successfully,  within  the  first  few 
days  after  birth;  and  Malgaigne  has  followed  a  similar  practice. 

"  From  all  my  experience  and  reflections,"  deduces  Mr.  Fergusson, 
"  I  am  more  than  ever  disposed  to  recommend  a  very  early  opera- 
tion. Within  the  last  twelve  months  I  have  operated  on  five  infants, 
all  of  them  under  three  months,  with  the  most  satisfactory  results  ; 
and  these  cases,  with  others  I  have  previously  had,  are  sufficient  to 
induce  me  to  pursue  a  similar  practice  in  all  instances  of  the  kind 
which  may  come  under  my  notice,  unless  there  be  some  apparent 
indication  not  to  interfere.  An  erroneous  impression,  as  I  suppose, 
prevails  that  children  are  remarkably  subject  to  convulsions  while 
undergoing  operations ;  and  this  is  often  urged  as  a  reason  for  not 
interfering  with  hare-lip  in  early  life.  Doubtless  convulsions  have 
occurred  in  some  of  these  cases ;  but  similar  efiects  have  been  pro- 
duced in  the  adult,  and  by  less  formidable  means,  too.  Sir  Astley 
Cooper  has  referred  to  several  examples  of  this  kind,  but  I  imagine 
they  must  be  rare  indeed.  I  once  asked  Dr.  Abercrombie,  of  Edin- 
burgh, the  result  of  his  experience  on  this  point,  and  he  could  not 
bring  a  single  instance  to  his  recollection  where  convulsions  could 
be  fairly  attributed  to  an  operation." 

"  At  what  period,"  says  Colles,  the  famous  Dublin  professor, 
"should  one  undertake  the  operation  for  hare-lip?  No  doubt  the 
earlier  you  perform  it  the  better  chance  you  will  have  of  a  speedy 


534  ORAL  DISEASES  AND  SURGERY. 

cure;  but  infants  at  a  very  early  age  do  not  bear  operations  well; 
many  of  them  will  be  seized  with  convulsions,  and  die,  if  subjected  to 
a  more  trifling  operation  than  this  we  have  been  considering.  I  think 
between  the  second  and  third  year  the  best  period." 

"There  are,"  says  Professor  Gross,  in  his  System  of  Surgery, 
"few  subjects  in  surgery  which  have  been  more  frequently  discussed 
during  the  last  quarter  of  a  century  than  the  question  of  the  period 
at  which  the  operation  of  hare-lip  may  be  best  performed.  My  own 
opinion  long  has  been  that  the  most  eligible  period  is  from  the  third 
to  the  sixth  month,  or  a  short  time  before  the  appearance  of  the  first 
teeth;  the  operation  is  then  usually  borne  well,  there  is  no  danger 
of  convulsions,  and  the  adhesive  process  generally  proceeds  most 
kindly.  In  very  simple  cases  I  do  not  hesitate  to  attempt  it  earlier ; 
and,  on  the  other  hand,  in  double  or  very  complicated  hare-lip  I 
almost  always  postpone  it  until  the  child  has  attained  its  second 
or  third  year." 

Dr.  D.  H.  Agnew  operates  at  any  period ;  is  influenced  onl}", 
even  during  the  process  of  dentition,  by  constitutional  condition. 
If  dentition  is  progressing  quietly,  that  is,  if  there  is  no  associated 
irritability,  he  can  see  no  reason  why  the  operation  may  not  be  per- 
formed just  as  well  at  this  time  as  at  any  other;  has  operated  in 
all  the  stages  of  this  process.  Dr.  A.  prefers,  however,  early  oper- 
ations ;  he  thinks  that  his  most  successful  cases  have  been  on  chil- 
dren who  had  not  attained  their  tenth  day.  So  far  as  interference 
with  sucking  is  concerned,  he  remarks  that  he  has  seen  a  child  take 
the  breast  almost  immediately  after  an  operation  has  been  com- 
pleted. 

Professor  Pancoast  entertains  about  the  same  views  as  are  ex- 
pressed by  Dr.  Agnew.  Dr.  Pancoast  gives  it  as  the  result  of  his 
very  extended  experience,  that  the  operation  may  be  about  as  well 
done  at  one  time  as  at  another.  Does  not  see  why  the  period  of 
dentition  is  to  be  so  cautiously  avoided.  Operates  at  any  period  of 
this  process,  if  there  are  no  contraindications  of  constitutional  dis- 
turbance. Has  operated  on  many  children  as  early  as  a  few  days 
after  birth,  with  the  happiest  results.  Does  not  find  the  operation 
interfere  materially  with  nursing. 

Professor  Henry  H.  Smith,  of  the  University,  says :  "As  respects 
the  period  for  the  operation,  the  earliest  possible  time  after  the 
tissues  seem  firm  is  to  be  selected,  usually  after  the  third  month  of 
infancy." 

Now,  although  we  have  here  cited  such  a  variety  of  opinions. 


OPERATIONS   UPON   THE  LIPS  AND    CHEEK.      535 

which,  to  the  inexperienced,  may  seem  confusing,  3-et,  when  we 
consider  the  different  circumstances  under  which  these  learned  and 
experienced  gentlemen  have  written  and  spoken,  we  are  enabled  to 
deduce  from  such  experiences  rules  for  guidance,  in  which,  if  my 
observation  at  all  serves  me,  will  be  found  data  as  reliable  as  we 
could  well  expect  to  possess.  The  views  of  such  as  I  have  men- 
tioned will  be  found  to  represent  fairly  the  diversity  of  opinion  ex- 
isting throughout  the  profession.  These  well-known  authorities  I 
have  especially  selected,  because,  being  public  teachers  and  writers, 
their  views  in  extenso  are  thereby  made  the  more  easy  to  come  at 
by  any  reader  specially  interested  in  this  subject. 

And  first,  in  making  up  the  sum  of  an  operation,  we  are  to  con- 
sider, regardless  of  the  age  of  the  patient,  the  amount  of  shock  such 
operation  is  to  give,  and  the  ability  of  the  patient  to  bear  this  shock. 
This  at  once  brings  up  the  character  of  the  defect,  and  the  amount 
of  operative  proceeding  necessary  to  its  cure.  A  bad  double  cleft 
would  inflict  a  much  greater  amount  of  pain  than  a  simple  single 
one,  and  consequently  would  inflict  a  shock  double  or  treble  in  force 
to  the  last.  Now,  every  man,  woman,  and  child  in  the  world  has  a 
certain  amount  of  physique,  and  no  more.  The  experience  and  phy- 
siological knowledge  of  the  surgeon  enable  him  to  weigh  the  life- 
force.  He  must  then  decide,  imprimis,  whether  or  not  his  patient 
is  equal  in  such  force  to  the  demands  of  the  operation. 

He  must  consider  the  condition  of  his  patient.  This  brings  up  the 
second  of  the  special  propositions  or  stand-points  from  which  the 
operation  is  to  be  studied.  The  possession  of  a  capable  physique 
does  not  imply  that  the  life-force  has  not,  like  the  tide,  its  ebb  and 
flow.  A  child  may  have  proper  development,  yet  at  the  very  time 
when  it  is  presented  for  operation  it  may  labor  under  temporary 
depression,  the  result  of  functional  disturbances.  A  child,  for  exam- 
ple, just  convalescent  from  cholera  infantum,  or  just  through  with 
some  of  the  exanthemata,  would  certainly  not  be  as  fit  a  subject  for 
operation  as  though  it  had  not  suffered ;  it  may  have  borne  the  de- 
mands made  upon  it  very  well,  and  come  out  of  the  ordeal  looking 
strong ;  but  then  it  is  the  last  feather  that  bends  the  camel ;  the  sys- 
tem that  endured  bravely  the  one  demand  may  not  have  a  residue 
of  force  on  hand  that  will  just  then  meet  another.  Give  such  a 
system  time;  get  it  back  to  the  condition  in  which  the  first  de- 
mand found  it,  and  you  then  have  it  certainly  capable  of  the  same 
resistance  and  of  the  same  endurance.  Again,  a  patient  may  not 
be  up  to  the  required  tone,  and  yet  circumstances  render  a  speedy 


536  ORAL  DISEASES  AND   SURGERY. 

operation  desirable.  "We  can  assist  nature.  Exercise,  fresli  air,  and 
proper  food  can  do  much.  The  last  may  imply  that  the  milk  of  the 
mother,  if  the  child  be  nursing,  be  exchanged  for  that  of  the  hired 
nurse.  Who  has  not  examined  the  milk  of  a  mother  or  wet-nurse 
and  found  it  greatly  deficient  in  some  important  constituent  ?  I  have 
seen  babes  growing  visibly  weaker  and  more  puny  day  by  day ;  I  have 
seen  physicians  baffled  because  they  could  find  no  one  portion  of  the 
economy  less  healthy  than  another.  I  have  seen  the  microscopist 
take  the  milk  on  which  such  a  babe  has  been  feeding,  and,  looking 
at  it  through  his  glasses,  find  it  half  made  up  of  cholesterin.  A 
change  of  milk  has  effected  immediate  change  in  the  child.  A  child 
may  have  fibrinous  blood  to  excess,  tending  to  undue  inflam- 
matory action,  or  the  lymph  which  such  blood  would  exude  might 
be  so  corpuscular  in  character  that  a  wound  would  at  once  take 
on  suppurative  action.  Either  condition  would  be  adverse  to  an 
operation.  Yet  we  have  antiphlogistics  for  the  one  and  tonics  for 
the  other.  A  seemingly  strong  child  may  be  in  a  typhoid  state,  and 
a  blushing  cheek  may  be  but  the  effect  of  hectic  or  excitement ; 
t3^phoid  blood  has,  comparatively,  no  fibrin.  If  you  were  to  perform 
an  operation  on  such  a  patient  you  w^ould  be  sure  to  have  a  failure 
for  your  pains.  I  have  had  under  my  care  patients  in  just  such  a 
typhoid  state,  where  the  pulse  would  be  bounding  and  the  face 
always  flushed  ;  such  a  quick  pulse  and  flush  is,  however,  the  result 
of  the  very  deficiency  in  the  blood,  A  child  nia}^  be  cutting  its 
teeth,  yet  this  does  not  necessarily  contraindicate  an  operation.  It 
is  not  every  child  that  has  convulsions  and  kindred  troubles  with 
the  cutting  of  its  teeth  ;  many  a  child  goes  through  the  whole  pro- 
cess of  dentition  without  cause  upon  which  to  ground  a  sob.  If  a 
child  is  brought  to  the  surgeon,  cutting  teeth,  with  an  operation  for 
hare-lip  to  be  performed,  and  there  is  associated  with  the  dentition 
no  general  or  special  local  disturbance,  why  should  he  not  proceed, 
caeteris  paribus,  at  once  to  operate  ?  I  can  see,  and  I  have  up  to 
this  time  met  with,  no  objections  to  so  doing. 

The  next  consideration  is  the  operation  itself, — the  modifications 
of  the  one  principal  operation,  and  the  variety  of  clefts  influencing 
such  modifications. 

A  basis  operation  might  best  be  represented  by  a  simple  Y-cleft, 
having  the  mesian  line  of  the  lip  as  its  center, — the  indication  being 
to  restore  such  lip  to  a  normal  contour.  On  examination  with  the 
glass,  we  find  that  the  normal  lip  has  no  break  in  its  continuity ;  we 
find  what  may  be  termed  the  center  of  the  lip  represented  at  its  free 


OPEBATIONS    UPON   THE  LIPS  AND    CHEEK.      537 

margin  by  a  projection  of  more  or  less  graceful  curve.  We  find,  extend- 
ing from  this  free  margin  up  to  the  nares,  and  bounded  laterally  l)y 
the  ali»  nasi,  a  fossa, — the  fossa  labialis.  From  this  fossa  we  find 
the  lip  on  either  side  spreading  itself  out  to  be  lost  in  the  cheek. 
To  meet  the  indications  of  this  case  we  must  remove  the  break  in 
the  continuity,  create  a  mesial  projection,  -and  give  to  the  center  a 
fossa.  To  fulfill  such  indications  requires  a  study  of  the  conditions 
from  a  surgico-artistic  stand-point.  We  want,  first,  to  remove  the 
cleft.  This  in  itself  is  easy  of  accomplishment ;  we  have  only  to  pare 
the  edges  and  sew,  or  pin,  the  raw  surfaces  together.  But  in  view- 
ing this  first  step  a  little  more  closely,  we  perceive  that  a  C(jninion 
V-paring  from  the  edges  of  the  V-break  would  defeat  our  purpose  in 
securing  either  a  center  fossa  or  a  mesial  projection  ;  the  mode  of 
bringing  the  parts  together  would  put  on  the  stretch  such  fibers  of 
the  orbicularis  as  are  associated  with  the  margin  of  the  lip,  while  all 
that  portion  farther  up  would  be  comparatively  relaxed ;  thus  our 
fossa  would  be  a  promontory,  and  our  soft  median  swell  would  be  a 
stretched  mucous  membrane.  Such  an  operation  would,  then,  in 
meeting  the  first  indication,  destroy  our  ability  to  fulfill  the  two  others. 
We  must,  therefore,  instead  of  the  Y-cut,  seek  a  better ;  for  on  the 
way  in  which  we  pare  our  edges  depends  the  fulfillment  of  all  three 
of  the  indications.  An  ellipse  suggests  itself,  and  such  a  paring  will 
meet  our  wants.  1st.  It  enables  us  to  bring  the  edges  of  the  cleft 
together.  2d.  The  center  of  the  ellipse  is  its  greatest  diameter,  and 
this  center  is  the  center  of  the  lip.  When  we  bring  together  this 
most  widely  separated  part,  it  necessarily  projects  the  most  yielding 
surface — and  such  surface  is  the  free  symphysis  of  the  lip  ;  thus  the 
second  indication  is  met.  3d.  The  greatest  stretch  on  the  muscle  is 
in  the  site  of  the  myrtiform  fossa,  with  a  necessary  relaxation  above 
and  below ;  and  thus  the  last  indication  is  met ;  for,  as  the  result  of 
such  a  condition  of  the  parts,  we  have  a  fossa  formed  and  a  promon- 
tory at  the  free  mesial  line. 

Bemarks. — The  paring  of  a  cleft  should  always  be  constant  in  the 

one  featui'e  of  being  Y-shaped,  as  reference  is  had  to  the  base  of  the 

"Y  looking  toward  the  throat;  this  allows  for  excess  in  the  retrac- 

Ition  of  the  skin  over  the  mucous  membrane.     If  this  precaution  is 

I  neglected,  a  difficulty  is  likely  to  be  experienced  in  the  gaping  of  the 

cutaneous  portion  of  the  wound. 

i  The  subject  of  retaining  the  parts  in  apposition,  with  regard 
j  to  suture  material,  has  elicited  much  controversy.  The  ordinary 
I  operation  is  as  follows.    After  you  have  pared  the  edges  of  the  cleft, 


538  ORAL  DISEASES  AND  SURGERY. 

take  up  a  needle  threaded  with  the  ordinary  waxed  silk,  pass  this 
through  the  free  marg-ins  of  the  lip  and  bring  the  parts  together ; 
this  is  to  insure  a  satisfactory  approximation  at  this  point.  Next 
take  two  ordinary  steel  pins  and  pass  them  at  equidistant  points  on 
the  lip, — they  must  go,  in  depth,  at  least  half  its  thickness ;  these 
pins  are  to  enter  and  emerge  at  least  five  lines  on  each  side  of  the 
fissure.  Silk  ligature  stuff,  in  the  shape  of  the  figure-of-8,  is  now 
to  be  passed  about  and  around  these  pins.  Adhesive  strips  are  next 
passed  over  the  pins,  a  slit  being  made  for  their  accommodation; 
the  object  of  these  strips  is  to  press  tissue  toward  the  wound,  in  this 
way  preventing  tension.  If  blood  oozes  out  and  clots  upon  the  liga- 
tures, it  has  been  considered  rather  favorable  than  otherwise,  as  it 
has  been  thought  to  add  to  the  support  of  the  parts.  After  two  or 
three  days  the  pins  are  carefully  removed  by  a  rotary  motion ;  the 
ligature  material  and  adhesive  strips  are  allowed  to  remain  from  four 
days  to  a  week  longer. 

The  ordinary  hare-lip  pin  is  objectionable ;  it  is  too  large.  The 
figure-of-8  ligature  in  connection  with  the  pin  is  equally  to  be  con- 
demned. Wherever  we  see  a  case  of  hare-lip  that  has  been  thus 
operated  on,  we  see  four  ugly  scars  on  either  side  of  the  cleft :  these 
are  the  points  at  which  the  pins  entered  and  emerged,  and  upon 
which  the  figure-of-8  ligature  made  its  greatest  compression ;  the 
parts  ulcerated,  and  the  scars  are  simply  the  cicatrices  from  the 
healing  of  such  ulcers. 

Yarious  means  have  been  suggested  to  be  employed  in  lieu  of  such 
a  dressing.  Dr.  Agnew,  in  a  conversation  I  had  with  him  lately  on 
the  subject,  informed  me  that  he  now  uses  silver  wire  altogether. 
He  simply  sews  the  parts  together  with  a  greater  or  less  number  of 
interrupted  sutures.  He  thinks  such  sutures  possess  great  advan- 
tages over  the  pins. 

Another  means  of  bringing  the  parts  together  that  has  been  sug- 
gested, is  the  employment  of  the  interrupted  suture  of  silk  from  the 
under  surface  of  the  lip.  In  one  case,  however,  where  I  tried  this 
method  the  result  was  very  unsatisfactory. 

Dr.  Washington  Atlee  has  suggested  a  suture  which  differs  only 
from  the  ordinary  pin  and  figure-of-8  in  that  he  employs  rings  of 
india-vuljbcr,  which  are  stretched  over  the  pins.  This  suture  for 
many  purposes  must  prove  an  admirable  addition  to  the  armamenta- 
rium chirurgicum ;  but  in  hare-lip  operations  it  has  no  advantage  that 
I  can  see  over  the  ordinary  figure-of-8,  inasmuch  as  the  same  strain,  if 
not  a  greater,  is  exerted  upon  the  points  at  which  the  rubber  is  sup- 


OPERATIONS    UPON  THE  LIPS  AND    CHEEK.      539 

ported  by  the  pins.  The  merit  claimed  for  this  suture  is,  that 
whether  a  part  swells  or  remains  normal,  the  compressing  force  con- 
tinues about  the  same. 

A  mode  of  securing  the  apposition  of  the  parts,  which  I  think  will 
be  found  very  satisfactory,  is  to  take  three,  four,  or  more  pieces  of 
silver  wire,— the  fewer  you  can  get  along  with  the  better,  the  gauge 
being  the  most  delicate  that  can  be  procured ;  pass  these  and  let 
them  emerge  at  lines  which  shall  very  nearly  correspond  with  the 
commissure  of  the  lips.  Next  take  a  strip  of  common  sheet-lead, 
and,  cutting  it  to  an  appropriate  size,  make  in  it  as  many  little  holes 
as  you  have  threads  of  silk  to  either  side  ;  pass  the  threads  through 
these  holes,  and  compress  on  each  a  McLean  button — i.e.  a  simple 
flat  shot.  Now,  with  the  fingers,  nicely  approximate  the  wound. 
This  satisfactorily  accomplished,  draw  up  the  wires  and  fix  them  o;i 
a  second  piece  of  sheet-lead,  as  in  the  first  instance.  If  the  center, 
which  is  the  point  of  the  wound,  tends  to  bulge  forward,  a  delicate 
compress  is  to  be  placed  over  it,  and  bound  to  its  place  by  a  vcrtico- 
labial  sling.  The  advantages  of  this  dressing  are,  that  it  may  be 
retained  for  weeks,  if  necessary.  It  is  entirely  unirritating.  The 
wound  is  perfectly  open  to  examination,  and,  more  than  all  this,  the 
threads,  being  unirritating  and  very  slight,  when  taken  away  leave 
no  sears. 

A  still  happier  dressing,  but  one  which  can  be  applied  only  on 
such  patients  as  have  reached  the  age  of  intelligence,  is  a  modifica- 
tion of  Dewar.  Dewar's  compressor  may  be  likened  to  the  ordinary 
double  hernia  truss.  It  consists  simply  of  a  spring  which, passes 
around  the  head,  having  a  small  pad  at  each  extremity.  The  piece 
is  of  such  circle  and  character  as  to  bring  the  pads  to  the  labial  com- 
missures. The  instrument  is  held  in  position  by  any  convenient 
means.  Dewar  holds  it  by  what  might  be  termed  a  fronto-sagitto- 
lanil)doidal  sling.  The  process  of  dressing  with  this  instrument 
would  be  as  follows.  After  making  the  paring  of  the  cleft,  cleanse 
the  parts  well  with  cold  water  (controlling  hemorrhage  by  pressure 
on  the  facial  arteries) ;  next  take  a  strand  of  the  common  silk  liga- 
ture material,  and  nicely  approximate  the  free  edges  of  the  lip,  pass- 
ing the  needle  on  the  under  side.  The  next  step  is  the  application 
of  the  compressor.  With  the  thumb  and  finger  force  the  tissue  of 
the  cheeks  toward  the  mesial  line  of  the  lip— this  approximates  per- 
fectly the  edges  of  the  wound ;  replace  your  fingers  by  the  com- 
pressor, and  the  parts  are  held  in  situ.  If  the  approximation  of  the 
wound  thus  made  should  not,  however,  be  satisfactory,  secondary 


540  ORAL  DISEASES  AND  SURGERY. 

compresses  of  linen  may  be  placed  more  immediately  about  the 
wound,  and  fixed  by  a  delicate  roller.  The  advantages  of  this  dress- 
ing will  be  at  once  apparent.  There  are  no  pins  or  ligatures  used, 
consequently  there  is  nothing  to  interfere  with  direct  union ;  there 
are  no  punctures  made  in  the  skin  ;  of  course  there  is  no  risk  of 
having  any  but  the  single  linear  scar,  and  even  this,  if  direct  union 
is  secured,  must  be  slight  indeed.  The  parts  can  be  exaniiiied  at 
any  time  wnthout  important  interference  with  the  apparatus. 

In  some  individuals  the  coronary  arteries  are  quite  large.  To  sup- 
press the  hemorrhage  from  these  vessels,  dependence  is  generally 
placed  on  the  pressure  exerted  in  bringing  together  the  edges  of  the 
wound.  If  such  pressure  does  not  answer,  or  if  we  should  prefer 
some  dressing  that  will  not  make  this  pressure,  light  ligatures  may 
be  thrown  around  the  vessels,  one  end  to  be  cut  off,  the  other  to  be 
brought  out  on  the  back  part  of  the  wound.  Ligatures,  however, 
are  to  be  avoided  when  possible,  as  they  interfere  with  proper  union. 

A  much  better  means  than  the  resort  to  the  ligature  is  compres- 
sion of  the  facial  arteries.  Such  compression  needs  to  be  kept  up 
but  for  a  short  time,  as  the  smaller  artery  soon  contracts.  Dewar's 
compressor  controls  the  hemorrhage  by  its  pressure  on  the  coronary 
arteries,  and  its  action  may  be  very  readily  imitated  with  the 
common  compress  and  roller. 

There  is  a  feature  associated  with  the  formation  of  the  linear 
cicatrix,  and  the  unsightly  notch  which  so  commonly  deforms  hare- 
lip patients,  that  I  do  not  remember  to  have  ever  seen  alluded  to, 
but  which  is  of  such  consequence  as  to  merit  the  closest  scrutiny. 
Is  it  the  fault  of  nature  or  the  fault  of  the  surgeon  that  the  oper- 
ation gives  any  cicatrix  at  all  ?  Cicatricial  tissue — tissu  inodu- 
laire,  as  Delpech  more  happily  terms  it — means  accidental  tissue 
— new  tissue  formed  from  granulations.  The  existence  of  inodular 
tissue  implies,  as  it  is  greater  or  less  in  amount,  that  a  wound  has 
healed  either  by  primary  or  secondary  adhesion,  and  certainly  not 
by  what  Mr.  Hunter  terms  union  by  first  intention,  or  what  Mr.  Paget 
calls  immediate  union.  If  a  wound  is  made  to  unite  by  first  inten- 
tion, there  cannot  possibly  be  any  observable  inodular  tissue  or  scar, 
because  so  little  new  tissue  has  been  formed,  blood-vessels  and 
nerves  have  been  brought  into  perfect  contact,  and  the  harmony  of 
the  parts  has  been  so  completely  restored  that  after  a  few  weeks  the 
closest  observation  fails  to  discover  the  seat  of  accident.  We  have 
familiar  examples  of  such  union  in  the  slight  cuts  we  are  constantly 
giving  ourselves  with  the  razor,  the  cuts  we  get  about  the  fingers, 


OPERATIONS   UPON  THE  LIPS  AND    CHEEK.      541 

etc.  Some  years  back  I  removed  from  the  parotid  region  of  a  youno- 
man  a  tumor  fully  the  size  of  a  hen's  egg.  The  flaps  were  adjusted 
with  the  greatest  care,  and  held  in  place  by  compresses  of  old  and 
fine  linen.  I  saw  this  gentleman  about  ten  weeks  after  the  operation 
and  so  immediate  had  been  the  union  that  it  was  impossible  to  say 
where  the  cut  had  been  made.  Mr.  Paget  mentions  very  large  wounds 
that  not  unfrequently  heal  in  this  perfect  manner.  One  ca'se,  that  of 
a  lady  who  had  been  operated  on  for  seirrhus  of  the  mammary  gland, 
might  be  specially  alluded  to.     Speaking  of  the  operation,  he°«ays : 

"  The  flaps,  which  w^ere  very  large,  had  been  carefully  laid  down, 
strapped  with  isinglass  plaster,  and  well  tended.  After  death,  whicli 
occurred  in  three  weeks,  from  erysipelas  and  phlebitis,  I  cutW  the 
edges  of  the  wound  with  the  subjacent  parts,  expecting  to  find  the 
evidences  of  union  by  organized  lymph,  or,  possibly,  blood;  but 
neither  existed  ;  and  the  state  of  the  parts  cannot  be  better  described 
than  by  saying  that  scarcely  the  least  indication  remained  of  either 
the  place  where  the  flap  of  skin  was  laid  on  the  fascia,  or  the  means 
by  which  they  were  united.  It  was  not  possible  to  distinguish  the 
relation  which  these  parts  held  to  each  other  from  that  which  natu- 
rally exists  between  subcutaneous  fat  and  the  fat  beneath  it.  There 
was  no  unnatural  adhesion;  but  the  subcutaneous  fat  which  did  lie 
over  the  mammary  gland  was  now  connected  with  the  fascia  over 
the  pectoral  muscle.  The  parts  were  altered  in  their  relations,  but 
not  in  their  structure.  I  could  find,"  continues  Mr.  Paget,  "small 
points  of  induration  where,  I  suspect,  ligatures  had  been  tied,  or 
where  possibly  some  slight  inflammation  had  been  otherwise  ex- 
cited ;  and  one  small  abscess  existed  under  the  lower  flap.  But,  with 
the  most  careful  microscopic  examination,  I  could  discover  no  lymjth 
or  exudation  corpuscles,  and  only  a  small  quantity  of  what  looked 
like  the  debris  of  such  oil  particles  or  corpuscles  of  blood  as  might 
have  been  between  the  cut  surfaces  when  the  flaps  were  laid  down. 
In  short,"  says  Mr.  Paget,  "this  was  union  by  first  intention;  it 
was  immediate,  at  once  in  respect  of  the  absence  of  any  intermedi- 
ate substance  placed  between  the  wounded  surfaces,  and  in  respect 
of  the  speed  with  which  it  was  accomplished." 

The  union  of  a  wound  by  adhesion  or  by  granulation  implies  a 
certain  amount  of  inflammatory  action,  and  the  exudation  and  or- 
ganization of  lymph.  This  is  the  way  in  which  hai-e-lip  wounds 
are  healed,  and  this  is  why  we  have  the  linear  cicatrix;  and  not  only 
the  cicatrix,  but,  according  as  the  union  has  simulated  or  departed 
from  the  immediate  type,  we  have  a  great  or  small  notch. 


542  ORAL  DISEASES  AXD  SURGERY. 

But  how  is  the  notch  formed  ?  The  explanation  is  simple  enough  ; 
but  it  is  not  that  generally  given  ;  at  least,  I  think  not.  The  notch  is 
the  result  of  the  natural  contraction  which  belongs  to  fibrous  tissue,  of 
which  fibrous  tissue  the  cicatrix  is  formed  ;  and  if  we  observe,  we 
will  find  that  where  this  linear  inodular  tissue  exists  in  excess, 
a  large  notch  is  always  associated  with  it.  If  we  need  further 
proof  to  convince  ourselves  that  such  contraction  is  the  cause  of  the 
notch,  we  have  only  to  remark  that  in  cases  of  lai'ge  cicatrices  the 
destruction  of  the  symmetry  of  all  the  surrounding  parts  has  inva- 
riably occurred ;  the  contraction  has  puckered,  as  it  were,  the  whole 
lip.  When  the  linear  cicatrix  is  very  limited,  the  notch  is  corre- 
spondingly small ;  and  these  conditions  could  not  so  uniformly  exist 
associated,  if  it  was  the  manner  of  the  paring  exclusively  that  gave 
the  notch,  and  not  the  contraction,  as  I  have  described. 

The  nearer  then  the  approach  to  a  union  by  first  intention  we  can 
make  in  hare-lip,  the  better  for  our  success  will  be  the  result.  But 
can  we  not  get  immediate  union  in  full  ?  This  would  imply  that  we 
have  artery  to  artery,  vein  to  vein,  nerve  to  nerve.  Well,  the  artery 
is  a  prominent  point  of  reference,  and  the  relations  of  surrounding 
parts  are  in  perfect  unison.  If  we  can  get  the  mouths  of  the  two 
arteries  together,  will  not  all  other  vessels  assume,  by  compulsion, 
inosculation  ?  We  may  try  for  this,  at  any  rate ;  such  care  will  neces- 
sarily insure  to  us  the  very  nicest  approximation  of  parts,  and  if 
what  is  termed  immediate  union  cannot  be  obtained,  we  may  at  least 
secure  to  our  patient,  by  such  care,  the  smallest  possible  scar. 

To  return  now  to  the  modifications  in  hare-lip,  and  the  oper- 
ations. 

The  first  modification  of  the  simple  cleft  described  is  where  the 
break  is  to  the  one  side  or  the  other,  being  bounded  in  either  in- 
stance by  the  mesial  line.  This  character  of  cleft,  particularly  so  far 
as  the  left  side  is  concerned,  is  by  far  the  most  common  type;  indeed, 
it  may  be  denominated  the  type  proper  of  hare -lip.  In  operating 
here,  it  is  readily  seen  that  the  simple  ellipse,  as  practiced  in  the 
previous  case,  will  not  answer.  Such  a  cut  would  give  the  labial 
swell  and  fossa  to  the  one  or  the  other  side  of  the  mesian  line, 
according  as  the  break  extended  right  or  left. 

In  these  cases  the  indications  are  met  by  the  operations  of  Mal- 
gaigne.  This  surgeon  makes  the  one  side  of  a  simple  Y-cut  on  the 
external  flap,  while  he  practices  the  semi-ellipse  on  the  mesial  flap. 
This,  it  is  seen,  brings  up  the  outside  flap,  and  projects  the  apex  of  the 
mesial  one.   A  modification  of  this  operation,  and  a  decided  improve- 


OPERATIONS    UPON  THE  LIPS  AND    CHEEK.      543 

ment,  in  mj  opinion,  is  one  first  suggested,  I  believe,  by  Dr.  Richard 
Levis.  This  consists  in  making  a  kind  of  double  V-cut  on  the  mesial 
flap.  The  knife  is  entered  just  below  the  nostril,  and  the  first  incision 
takes  the  line  of  the  one  side  of  the  Y.  On  nearing  the  free  surface, 
however,  this  direction  is  changed,  and  a  second  V  is  cut  out  of  the 
substance  of  the  flap.  This  mode  of  operating  secures  a  very  nice 
labial  swell,  and  will  be  found  sufiiciently  easy  of  performance.  To 
bring  out  to  the  level  the  notch  thus  made,  implies  some  force ;  and 
if  it  should  be  designed  to  use  Dewar's  compressor,  it  nmst  always 
be  associated  with  a  point  of  silver  suture ;  the  suture  being  intro- 
duced from  the  mucous  surface. 

Another,  and  the  next  most  common  variety  in  hare-lip,  is  that  in 
which  the  break  is  double — that  is,  the  single  break  is  divided  into 
two  parts  by  a  teat  which  starts  out  from  the  apex  of  the  cleft;  this 
teat  is  seldom  more  than  half  the  width  of  the  lip.  For  the  correc- 
tion of  this  defect,  various  means  are  resorted  to.  Some  surgeons 
cut  out  the  teat,  thus  converting  the  double  into  a  single  break, 
making  the  basis  cleft  as  described.  Others,  on  the  contrary,  after 
paring  all  the  four  sides,  tease  and  strain  the  center  piece  or  teat 
until  they  get  it  on  a  level  with  the  rest  of  the  lip.  Both  of  these 
operations  are  veiy  objectionable.  The  first  takes  away  an  unneces- 
sary amount  of  substance  from  the  lip,  thus  giving  a  tense,  stretched 
appearance  to  the  part;  while  the  natural  resiliency  which  belongs 
to  most  tissue  insures,  from  the  second  manipulation,  a  character  of 
notch  or  central  depression  almost  as  unsightly  as  the  original  de- 
formity. In  this  simple  form  of  double  hare-lip,  I  think  it  will  be 
found  the  most  satisfactory  operation  to  pare  the  lateral  flaps  in  the 
elliptical  form  as  described,  while  the  center  teat  should  bo  pared 
into  the  Y-form,  the  base  being  to  the  septum  nariuni.  All  the 
parts  will  thus  be  found  capable  of  a  neat  approximation ;  the  teat 
doing  its  share  more  or  less  in  filling  up  the  break.  The  approxi- 
mation is  to  be  made  as  in  the  mode  described. 

A  second  form  of  double  hare-lip  is  that  in  which  the  alveolar 
process  is  associated  with  the  teat.  This  is  termed  complicated 
hare-lip.  The  portion  of  process  projecting  into  the  cleft  is  gen- 
erally an  intermaxillary  formation,  and  holds  the  germs  or  de- 
veloped incisor  teeth— generally  the  centrals  alone.  The  correction 
of  this  defect  implies  a  somewhat  formidable  operation.  The  first 
step  consists  in  separating  well  the  lip  from  its  reflection  over  the 
process.  Next  the  gum  is  separated  thoroughly  from  the  projecting 
-bone,  which  bone  the  third  step  in  the  operation  removes  down  to 


544  ORAL  DISEASES  AND  SURGERY. 

the  natural  curvature  of  the  parts,  either  by  means  of  saw,  chisel,  or 
cutting  forceps.  For  myself,  I  prefer  the  chisel ;  it  is  certainly  a 
much  more  convenient  instrument  than  the  Hey's  saw  so  commonly 
employed.  A  straight  and  curved  chisel  should  always  be  at  hand. 
If  in  this  third  step  of  the  operation  the  anterior  palatine  artery  is 
wounded,  the  resulting  hemorrhage  is  easily  controlled,  either  by 
taking  up  the  vessel  or  by  touching  it  with  one  of  the  astringents ;  or, 
if  neither  of  these  means  suffices  for  its  accomplishment,  the  artery 
may  be  touched  with  a  red-hot  cauterant  needle,  or  it  may  be  plugged 
with  a  point  of  pine  stick.  The  bone  removed,  the  flaps  of  gum  may 
be  laid  back  in  the  cavity,  where  they  will  remain  sufficiently  approxi- 
mated without  the  employment  of  any  sutures.  The  operation  upon 
the  lip  may  now  be  performed  at  once  in  the  manner  described ;  or, 
if  the  force  of  the  patient  is  too  much  exhausted,  it  may  be  left  for  a 
future  period. 

These  are  the  two  principal  forms  of  double  hare-lip.  An  appre- 
ciation of  the  operations  required  for  their  cure  will  enable  the  sur- 
geon to  meet  satisfactorily  any  modifications  that  may  present  on 
either  of  them  ;  and  these  modifications,  it  is  to  be  suggested,  are 
constantly  occurring.  Let  us,  for  a  single  moment,  refer  to  an  un- 
complicated double  hare-lip,  where  the  center  piece,  or  teat,  as  I  have 
called  it,  might  be  found  so  large  and  square  as  fairly  to  divide  the 
lip  into  three  parts.  Xow,  here  the  mesian  line  of  the  lip  would  be 
formed  by  the  center  piece ;  it  would  therefore,  I  think,  suggest 
itself  to  any  one  that  either  side  of  the  cleft  was  to  be  treated  as  a 
separate  hare-lip — that  is,  the  whole  manipulation  might  be  done  at 
the  one  sitting ;  but  there  would  have  to  be  symmetrical  parings 
made  of  either  cleft.  In  such  a  case,  we  have  also  to  take  into  the 
account  the  concavity  made  on  either  of  the  sides  of  our  fissure,  as 
reference  is  had  to  the  influence  exerted  on  the  free  margin  of  the 
lip  ;  for  here  of  course  we  require  no  swell.  Whether,  again,  in 
these  really  double  cases,  Ave  would  first  operate  on  the  one  side, 
and,  when  this  was  cured,  on  the  other,  is  a  matter  which  should 
be  left  to  the  judgment  of  the  operator.  Many  surgeons  prefer  to 
correct  the  whole  deformity  at  once.  If  we  should  do  this,  the 
operation  would  only  deviate  from  the  principles  laid  down,  as 
regard  would  be  had  to  approximating  the  parts.  If  the  center 
piece  might  be  small,  I  think  it  would  be  found  the  most  satisfactory 
practice  to  pass  the  pins,  Avire,  or  whatever  suture  material  might 
be  used,  directly  from  one  lateral  flap,  on  through  the  center  piece, 
to  and  through  the  other,  thus  uniting  all  the  parts  together  by  a 


OPERATIONS    UPON  THE  LIPS  AND    CHEEK.      ,045 

common  suture.  If,  on  the  contrary,  a  center  piece  is  broad  and 
well  covered  by  skin,  I  think  that  the  greatest  good  would  be  found 
to  be  secured  by  using  two  sets  of  ligatures.  As  regards  the  single 
or  double  operation,  I  myself  am  influenced  by  the  width  of  the 
middle  piece,  the  tenseness  or  laxity  of  the  tissue  of  the  lip,  and  the 
endurance  and  condition  of  the  patient.    - 

Another  modification  of  the  double  hare-lip  is  one  in  which  there 
is  a  projection  into  the  cleft  of  the  incisor  teeth,  the  alveolar  process 
itself  being  sufficiently  normal  to  allow  of  non-interference  with  it. 
This  modification  is  commonly  met  with  in  the  adult  alone,  or  at 
least  after  second  dentition.  The  projection  of  the  teeth  is  the 
natural  result  of  the  lack  of  external  support  from  the  labial  de- 
ficiency; the  tongue  has  actually  pushed  them  outwardly.  This 
explanation  will,  I  am  sure,  seem  strange  only  to  such  as  are  un- 
acquainted with  the  exceeding  mobility  of  the  dental  organs  under 
slight  but  continued  force.  It  is  certainly  the  true  cause  of  such 
projection.  In  a  case  of  this  kind,  a  preliminary  operation  is  the 
removal  of  the  teeth.  If,  now,  six  months  are  allowed  to  intervene 
before  attempting  the  operation  on  the  lip,  the  alveoli  of  the  ex- 
tracted teeth  will  be  found  to  have  receded,  through  absorption, 
quite  the  eighth  of  an  inch.  The  second  operation  is  then  to  be 
done  secundum  artem.  This  waiting  on  the  process  of  absorption 
will  be  found  greatly  to  conduce  to  a  successful  result. 

A  still  better  though  more  tedious  mode  of  correcting  such  a  de- 
formity is  by  first  bringing  the  projecting  teeth  back  to  their  normal 
place  in  the  arch,  through  the  agency  of  elastic  ligatures.  This  is  a 
perfectly  feasible  operation,  and  not  at  all  difficult  of  performance. 
By  such  a  preliminary  procedure  we  not  only  get  the  teeth  out  of 
the  way,  but  we  save  to  the  patient  these  valuable  organs.  To 
make  and  appl}"  such  a  ligature,  we  have  only  to  take  a  slip  of  com- 
mon india-rubber  and  attach  at  either  end  loops  of  silk.  We  next 
take  these  loops  and  place  them  over  certain  of  the  molar  teeth ;  it 
is  entirely  immaterial  which.  The  center  or  rubber  part  is  next 
stretched  forward  and  laid  over  the  labial  faces  of  the  teeth  to  be 
pulled  back.  It  is  astonishing  how  quickly  and  powerfully  such  a 
force  will  act  upon  the  teeth.  In  two  or  three  weeks,  at  most,  the 
teeth  may  be  brought  into  their  proper  line.  To  secure  them  in 
situ,  and  prevent  their  being  again  pushed  forward,  we  have  only  to 
keep  them  ligatured  in  any  convenient  manner  until  the  operation 
on  the  lip  is  made. 

Cleft  of  the  lip,  as  previously  remarked,  is  common  to  almost 

35 


546  OFAL   DISEASES  AND  SURGERY. 

every  case  of  cleft  of  the  hard  palate.  It  has  always  been  deemed 
very  important  in  these  cases  that  an  operation  on  the  lip  should 
be  performed  as  early  as  possible ;  it  is  thought  to  favor  the  union 
of  the  bony  cleft.  In  these  cases  the  operation  differs  from  that 
suited  to  any  ordinary  one  only  when  there  is  projection  of  one  or 
both  alveolar  prominences  into  the  break.  In  such  instances,  if  the 
projection  is  very  marked — that  is,  so  much  so  as  to  prevent  the 
bringing-  together  of  the  lips  over  them — we  may  perhaps  be  al)le  to 
do  nothing  better  than  cut  away  the  parts.  This,  however,  is  always 
to  be  avoided  where  possible, —  first,  because  we  thus  destroy  the 
germs  of  the  teeth ;  and,  secondly,  because,  if  by  any  means  we  can 
get  union  of  the  lip,  the  parts  in  their  development  will  come  mutu- 
ally to  accommodate  each  other.  In  such  cases  it  is  recommended 
by  some  authors  that  we  endeavor  to  bend  back  these  juttings  of 
bone,  turning  them  in  toward  the  mesial  line.  Where  this  can  be 
done,  it  answers  a  very  admirable  purpose.  Still  another  mode — 
after  the  method  which  I  suggested  for  the  complete  relief  of  this 
character  of  cleft — consists  in  the  employment  of  the  fronto-occipito- 
labial  elastic  sling.  This  sling  is  so  applied  that  it  pulls  upon  the 
projecting  process  backward  from  the  occiput.  It  will  certainly 
fulfill  the  indications;  but  its  employment  is  not  unattended  with 
trouble. 

Cases  of  double  hare-lip  not  uufrequently  occur  where  the  center 
slip  is  so  associated  with  the  septum  of  the  nares  as  to  make  the 
parts  seem  as  one.  If  there  was  not  the  loss  of  material  from  the 
lip,  the  septum  would  bear  being  described  as  in  a  state  of  hyper- 
trophy. Again,  the  lost  part  from  the  lip  is  sometimes  found  at- 
tached to  the  very  tip  of  the  nose,  giving  to  the  patient  the  appear- 
ance of  laboring  under  lipoma.  These,  together  with  all  the  anomalies 
in  this  direction,  are  first  to  be  studied,  as  regards  their  cure,  from 
the  artistic  stand-point.  The  surgeon  knows  where  and  what  he 
can  afford  to  cut;  he  knows  what  nature  will  do  in  the  case;  it 
only  remains  for  him  to  consider  well  his  incisions — where  he  shall 
make  them,  and  what  is  to  be  the  result  before  the'  operation  is 
attempted. 

A  useful  study  is  found  in  the  examination  of  examples.  If  we 
familiarize  ourselves  with  all  kinds  of  cases,  and  if — what  is  still 
better — we  represent  the  morbid  anatomy  in  india-rubber,  and  thus 
devise  and  try  experimental  operations,  we  shall,  I  am  sure,  find  the 
subject  of  hare-lip  grow  simple  enough. 

Excellent  studies  will  be  found  pictured  in  the  following  works : 


OPERATIONS    UPON  THE  LIPS  AND    CHEEK.      547 


&  Mutter's  Surgery,  page  1S1 ;  Eriehsen's  Surgorv,  page 
Jross's  Surgery,  pages  611,  612,  617,  vol.  ii.;   Fergusson's 


Liston 

690;  Gi 

Surgery,  page  494. 

Addenda.— In  operating  for  hare-lip,  always  first  dissect  the  lip 
well  off  from  its  attachment  to  the  gum. 

In  paring  the  fissures,  the  young  sm-geon  is  much  more  apt  to 
remove  too  little  than  too  much. 

In  paring  out  the  apex  of  the  cleft,  be  sure  to  freshen  perfectly 
the  extreme  point  of  such  apex.  This  is  oftentimes  neglected;  and 
an  ugly  pucker  is  the  result. 

The  paring  for  hare-lip  is,  perhaps,  best  made  on  a  wooden  spatula. 

Few  instruments  are  really  required  in  this  operation.  A  scalpel 
and  forceps,  together  with  such  ligature  material  as  it  is  designed  to 
employ,  will  answer  the  purpose  well  enough. 

The  best  mode  of  operating  on  the  infant  is  for  the  surgeon  to 
seat  himself  face  to  face  with  an  assistant.  The  child  being  ether- 
ized, the  surgeon  lays  its  body  over  his  own  knees,  the  head  being 
supported  by  the  assistant.  Upon  the  incision  being  made  on  one 
side,  the  assistant  grasps  the  lip  between  the  thumb  and  finger, 
compressing  the  coronary  artery.  When  the  artery  of  the  opposite 
side  is  cut,  he  secures  this.  Both  are  steadily  held  until  the  oper- 
ator is  ready  to  coaptate  the  wound. 

In  operating  on  the  adult,  I  think  it  will  be  found  the  most  con- 
venient plan  to  stand  behind  the  patient ;  such  a  chair  being  used, 
and  the  head  being  placed  in  such  position,  as  recommended  in  the 
operation  of  staphyloraphy. 

Another  very  convenient  manner  is  to  sit  in  front  of  the  patient, 
the  head  being  supported  against  the  breast  of  an  assistant. 

When  plaster  is  used  to  assist  the  ligatures,  silk  gauze  and  col- 
lodion  are  to  be  preferred  ;  this  leaves  the  wound  constantly  ex- 
posed to  inspection,  and  is  a  light  and  most  effective  dressing. 


CHAPTER    XXXYI. 

OPERATIONS   UPON    THE   LIPS   AND   CHEEK. 

As  the  result  of  disease  or  accident,  persons  occasionally  suffer 
from  contraction  of  the  orifice  of  the  mouth ;  a  most  unhappy  con- 
dition, both  as  regards  the  appearance  and  the  comfort  of  the  in- 
dividual. Such  contractions  are  represented  in  the  plate,  Subfigs. 
7,  8,  and  9. 

Dieffenbach,  of  Berlin,  who  interested  himself  very  much  in  the 
surgery  of  the  mouth,  suggested  and  practiced  for  the  relief  of  these 
deformities  an  operation,  which,  with  occasional  slight  and  unim- 
portant modifications,  is  the  one  still  generally  employed. 

Dieffenbach's  operation  is  performed  on  the  following  principles : 
Map  out  with  pen  and  ink  on  the  tissues  such  lines  and  angles  as 
shall  meet  your  approbation  of  what  the  proper  mouth  should  be. 
These  lines  are,  of  course,  to  be  in  conjunction  with  the  existing 
orifice  or  commissure,  wherever  or  however  situated, — that  is,  the 
relation  of  the  existing  orifice  must  be  studied  as  it  is  to  have  asso- 
ciation with  the  cuts  you  are  to  make.  Thus,  if  we  glance  at  Fig.  7, 
we  at  once  appreciate  the  necessity  for  enlarging  the  mouth  by  sec- 
tions equilateral  to  the  center,  as  certainly  it  is  apparent  enough 
that  only  by  such  a  form  of  incision — which  I  have  caused  to  be 
represented  by  a  line — could  we  secure  the  end  at  which  we  aim. 
Fig.  8,  on  the  contrary,  would  demand  an  operation  exclusively 
lateral ;  for  here  the  mouth  at  its  right  angle  is  as  perfect  as  we 
could  hope  to  make  it.  Fig.  9  presents  us  with  a  complication  on 
these  simple  conditions.  These  complications  might  be  multiplied 
almost  ad  infinitum;  for  who  may  say  in  what  condition  a  wound 
or  other  injury  shall  leave  a  part?  At  any  rate,  the  surgeon  is  to  be 
prepared  to  meet  any  and  all  kinds  of  modifications.  These  three 
figures  give  perhaps  as  just  an  idea  of  the  mechanico-surgical  indi- 
cations of  such  cases  as  any  others  that  might  be  drawn.  Figs,  t 
and  8  are  from  life ;  9  is  one  made  up  to  represent  a  not  unlikely 
aspect.*     It   exhibits,   as    is   seen,  a   combination   of  the   cicatrix 

*  Fig.  9  is  not  correct  to  the  text :  add  to  it  the  defect  in  Fig.  1,  and  it  will 
be  right. 

(548) 


OPERATIONS   UPON  THE  LIPS  AND    CHEEK.     549 

and  hare-lip.  In  this  last  case  is  suggested  of  itself  the  necessity 
for  a  double  operation.  The  mouth  is  to  be  made  smaller  before  i't 
would  be  at  all  proper  to  attempt  making  it  larger.  We  must 
first  perform  a  hare-lip  operation.  Imagine  this  "done,  and  then 
further  the  condition  in  which  such  operation  would  leave  the 
orifice.  If  we  refer  to  the  drawing,  we  see  that  the  opening  is  now 
at  what  is  properly  the  right  angle  of  the  mouth,  and  an  operation 
for  the  making  of  a  proper  commissure,  if  there  was  no  hare- or  cleft- 
lip,  would  be  precisely  the  same  lateral  incision  as  that  indicated 
in  case  8.  But  then  it  is  to  be  remarked  that,  after  the  first 
operation  was  performed,  the  orifice  would  not  be,  as  now,  at  the 
proper  right  angle.  The  bringing  of  the  cleft  together  would  pull 
it  naturally  toward  the  mesial  line.  Thus,  then,  it  is  made  a  cross 
between  7  and  8  ;  it  is  not  like  7,  because  it  is  not  exactly  in  the 
mesial  line,  and  it  would  not  be  like  8,  because  it  has  been  drawn 
from  the  proper  right  angle  toward  the  mesial  line.  Here,  then,  the 
complication  has  materially  changed  the  indications  of  the  principal 
operation.  The  incisions  would  have  to  be  bilateral,  but  yet  not 
equally  so  as  reference  is  had  to  the  false  commissural  center,  but 
only  as  reference  would  be  made,  say  to  the  septum  narium  or 
any  other  fixed  mesial  line  proper.  The  space  between  the  central 
incisor  teeth  would  be  a  good  mesial  center  to  take. 

These  features  well  considered,  we  take  up  a  pair  of  sharp-pointed 
scissors,  and,  passing  a  finger  of  the  left  hand  into  the  mouth,  enter 
one  blade  of  the  scissors  down  through  the  tissues  toward  the  finger, 
sparing  alone  in  the  puncture  the  mucous  membrane ;  the  blade  is 
now  pushed  forward  toward  the  mesial  line,  and  the  tissues  incised, 
as  indicated  by  the  superior  right  lateral  half  of  the  ellipsis  repre- 
sented by  the  line  in  Fig.  7.  The  scissors  are  now  reintroduced  at 
the  previous  point  of  entrance,  and  the  cut  made  on  the  inferior  lip 
precisely  as  was  done  above.  Next  dissect  out  the  triangular  piece. 
Repeat  these  incisions  on  the  opposite  side.  The  next  step  con- 
siders the  incision  of  the  mucous  membrane.  This  is  done  simply 
by  dividing  it  down  the  center  to  within  two  or  three  lines  of  the 
angle  of  the  wound ;  it  is  then  to  be  brought  over  the  cut  surfaces 
and  attached  by  means  of  the  interrupted  suture  to  the  skin. 

This  mode  of  rercstablishing  the  orifice  of  the  mouth  is  thought 
by  many  surgeons  to  be  the  best  that  can  be  employed.  Professor 
Smith,  of  the  University,  reports  two  cases  operated  on  after  this 
method,  which  resulted,  he  says,  to  his  entire  satisfaction. 

The  late  Professor  Miitter  reports  similar  satisfactory  results. 
The  following  interesting  case  is  from  his  practice : 


550  ORAL  DISEASES  AND  SURGERY. 

The  patient  was  a  daughter  of  a  respectable  practitioner  of  medi- 
cine residing  in  South  Carolina,  and,  at  the  time  the  accident 
productive  of  the  deformity  occurred,  was  about  eleven  years  of 
age;  of  fine  general  health,  though  of  a  temperament  strongly 
lymphatic. 

In  the  commencement  of  the  winter  of  1835,  while  at  play  with 
her  companions,  she  was  by  some  means  or  other  thrust  against  a 
heated  stove,  by  which  her  hands,  arms,  neck,  and  the  lower  part  of 
her  face  were  severely  burned. 

Her  wounds  were  treated  in  a  most  judicious  manner  by  her 
father;  but,  in  spite  of  all  his  efforts,  those  about  the  mouth  cicatrized 
with  so  much  contraction  that  the  entrance  into  this  cavity  was 
almost  obliterated.  As  soon  as  the  tenderness  of  the  part  was 
somewhat  diminished,  he  commenced  a  course  of  treatment  calcu- 
lated to  restore  this  orifice  to  its  natural  size.  He  first  began  by 
introducing  sponge  tents,  which  Avere  allowed  fully  to  distend  them- 
selves ;  but,  after  repeated  attempts  with  them,  by  which  he  caused 
the  child  much  suffering  without  materially  benefiting  her,  they 
were  abandoned. 

He  then  attempted  to  dilate  it  by  first  making  an  incision  about 
six  lines  in  length,  extending  from  each  angle  of  the  mouth  in  an 
outward  and  nearly  horizontal  direction,  and  afterward  introducing 
the  tents  to  prevent  the  lips  of  the  Avound  from  uniting.  This  ap- 
peared at  first  to  be  productive  of  some  good ;  but  in  a  short  time 
they  contracted  and  cicatrized,  and  the  patient  remained  in  as  un- 
comfortable a  condition  as  before. 

Finding  himself  foiled  in  both  attempts,  he  determined  to  bring 
her  to  Philadelphia  for  the  purpose  of  consultation.  She  was  ac- 
cordingly brought  on,  and  became  a  patient  of  Professor  Miitter,  who 
says,  "When  I  first  saw  her,  nearly  a  year  had  elapsed  since  the 
occurrence  of  the  accident.  Her  appearance  at  the  time  was  very 
singular.  Firm  and  dense  cicatrices  nearly  surrounded  the  mouth, 
but  were  most  marked  on  the  lower  lip  and  about  the  angles; 
while  the  orifice  of  this  cavity  was  barely  large  enough  to  admit 
the  point  of  the  finger,  and  presented  an  oval  form.  The  cicatrices 
of  the  incisions  made  by  her  father  were  also  very  apparent  at  each 
angle.  Her  general  health  was  perfect ;  and  it  was  only  on  account 
of  the  deformity  and  difficulty  of  taking  her  food  that  the  operation 
was  requested.  Her  speech  was  not  much  afifected ;  although  some 
of  the  labial  sounds  were  imperfectly  pronounced.  The  lining  mem- 
brane of  the  mouth  was  perfectly  normal." 


OPERATIONS   UPON  THE  LIPS  AXD    CHEEK.      551 

"From  the  history  of  the  case,"  says  Prof.  M.,  "I  concluded  it 
would  be  utterly  useless  to  attempt  a  cure  by  the  repetition  of  the 
measures  already  employed,  and  which  are  the  only  ones  usually  had 
recourse  to.  I  therefore  proposed  the  operation  devised  by  Dietfen- 
bach,  and,  her  father  consenting,  it  was  accordingly  performed  on 
the  28th  of  the  month  of  consultation. 

"  The  operation  completed,  a  common  roller  bandage  was  applied, 
as  in  cases  of  fracture  of  the  lower  jaw,  in  order  to  prevent  any  de- 
rangement of  the  wounds.  The  patient  was  then  placed  in  bed,  with 
her  head  elevated,  and  as  she  had  just  before  the  operation  eaten 
freely  of  some  light  food,  ordered  to  take  no  nourishment  of  any  kind 
until  the  next  visit,  and  to  be  perfectly  silent. 

"29th.  Passed  a  good  night;  slept  well ;  no  fever,  and  complains 
of  no  pain;  parts  merely  a  little  sore;  needles  all  in  place;  writes 
that  she  is  hungry.  Ordered  thin  oat-meal  gruel  as  diet,  which,  as 
Avell  as  her  drink,  is  to  be  given  with  a  small  teaspoon. 

"30th.  Quite  as  well  as  yesterday;  everything  in  place;  bowels 
costive  ;  ordered  an  injection  of  white  soap  and  water  ;  diet  as  before. 

"  31st.  Complains  of  stiffness  in  the  wounds,  but  no  pain  ;  dress- 
ing all  secured  ;  injection  had  operated  well ;  pulse  natural ;  ordered 
chicken  soup  for  diet. 

"Dec.  1st.  The  bandages  were  removed,  and  the  first  dressing 
commenced.  The  sutures,  which  had  been  closely  bound  down  to 
the  parts  by  blood,  were  carefully  softened  with  warm  water  and  cut 
away.  As  soon  as  they  were  removed,  and  the  parts  properly  dried, 
the  most  gratifying  exhibition  of  the  success  of  the  operation  was 
afforded.  On  both  sides,  union  between  the  everted  mucous  mem- 
brane and  the  margins  of  the  wounds  had  taken  place  nearly  through- 
out, and  the  new  lips  presented  an  appearance  almost  natural.  Some 
of  the  needles  were  then  removed  ;  but,  as  there  appeared  to  be  a 
feebleness  in  the  adhesion  at  some  points,  the  needles  passing 
through  them  were  allowed  to  remain,  and  a  thread  cast  loosely 
around  them.     The  bandage  around  the  head  was  also  reapplied. 

"2d.  Second  dressing,  parts  all  firm  and  healthy;  the  remaining 
needles  were  now  removed,  and  the  bandages  only  reapplied,  which 
w-as  done  to  prevent  talking;  no  pain  in  the  part,  and  the  patient  in 
fine  spirits.  Ordered  bowels  to  be  opened  with  an  injection,  and  the 
diet  to  be  more  nutritious,  but  still  liquid. 

"iS'othing  remarkable  occurred  in  the  subsequent  treatment;  all 
dressings  were  taken  off  on  the  loth,  and  the  child  allowed  to  pur 
sue  her  ordinary  course  of  life.     The  mouth  presented  a  very  good 


552  ORAL  DISEASES  AND  SURGERY. 

appearance,  though  the  lips  were  somewhat  thinner  than  natural, 
and  there  was  some  difficulty  in  bringing  them  in  close  contact,  espe- 
cially at  the  central  portions." 

Mr.  Listen  reports  a  case  of  equal  interest.  Mrs.  H.,  aged  twenty- 
two,  was  knocked  down  in  a  brawl,  and  a  man  jumped  upon  her,  lacer- 
ating and  bruising  her  cheek  and  mouth  extensively,  and  fracturing 
her  jaw.  She  went  to  St.  Thomas's  Hospital,  where  her  jaw  was  put 
up  and  bandaged.  These  were  not  removed  for  some  time ;  and,  when 
taken  off,  the  wound  on  the  right  side  of  the  mouth  was  found  healed, 
and  the  cicatrix  considerably  contracted;  since  then  the  contraction 
has  continued  somewhat,  and  now  is  so  small  that  she  can  scarcely 
get  any  solid  food  to  pass  her  lips.  There  is  a  large,  dense,  white 
cicatrix  on  the  right  side  of  the  mouth,  rather  puckered,  and  sharp 
toward  the  angle  of  the  mouth.  An  operation  was  performed  on 
the  23d.  Mr.  Listen  removed  a  triangular  portion  of  the  cicatrix 
on  the  right  side  of  the  mouth,  dissecting  it  off  the  mucous  mem- 
brane, which  was  then  divided  to  the  extent  of  the  external  wound. 
Lint  dipped  in  cold  water  was  then  laid  over  the  surface,  to  suppress 
the  oozing  of  blood,  which  was  by  no  means  considerable.  About 
five  hours  after  the  operation,  all  oozing  having  ceased,  the  mucous 
membrane  was  turned  over  the  cut  edge  of  the  cicatrix,  and  united 
by  three  or  four  points  of  suture  to  the  skin  of  the  cheek ;  by  this 
means  a  mucous  surface  was  secured  to  the  newly-formed  prolabium, 
and  the  gradual  cicatrization  and  consequent  contraction  dispensed 
with. 

History  of  the  case,  from  notes  : 

24th.  A  little  swelling  around  the  wound ;  not  much  pain. 

25th.  The  sutures  were  removed  to-day.  Adhesion  appears  to 
have  taken  place  between  the  mucous  membrane  and  skin.  Water 
dressing  to  be  applied  to  the  lips. 

Nov.  1.  The  water  dressing  has  been  continued;  union  between 
the  mucous  membrane  and  skin  took  place  to  a  considerable  extent 
by  the  first  intention.  The  remaining  parts  are  granulating  favor- 
ably.    The  mouth  is  much  improved  in  appearance  and  usefulness. 

4th.  The  lip  nearly  healed,  only  a  small  sore  remaining  in  the 
lower  lip.  Red  wash  dressing  to  be  applied  to  it.  Discharged  much 
relieved. 

A  modification  of  the  mode  of  Dieffenbach,  which  I  would  sug- 
gest, and  which  I  am  confident  will  yield  still  better  results,  is  an 
association  with  these  surgical  means  of  a  mechanical  appliance. 

After  the  operation,  as  described,  has  been  performed,  and  time 


OPERATIONS    UPON  THE  LIPS  AND    CHEEK. 


553 


has  been  given  for  union  of  the  reflected  mucous  membrane,  let  such 
an  appliance  as  I  have  here  figured  (mouth-stretcher,  it  might  be 
called)  be  prepared  and  slip  it  between  the  lips.     This  stretcher 


Fig.  103. 


represents  a  properly-shaped  mouth ;  the  lips  in  the  whole  of  their 
,  circumferences  are  caught  and  held  by  the  gutter  of  the  apparatus, 
and  thus  not  only  is  the  healing  influenced  to  a  desired  shape,  but 
undue  cicatricial  contraction  is  prevented. 

If  it  is  objected  that  such  an  instrument  would  look  ungainly  in 
the  mouth,  I  have  only  to  answer  that  after  the  first  week  or  two, 
there  would  exist  no  occasion  for  its  constant  wearing;  it  might  be 
entirely  dispensed  with  during  the  day  and  be  worn  only  at  night. 
Such  use  of  it,  however,  should  be  continued  at  least  six  mouths,  if 
we  would  have  the  cure  perfect. 

An  advantage  that  would  be  yielded  by  such  an  appliance  to  a 
bungling  operator  would  be  that  it  would  naturally  correct  any  im- 
perfection in  his  operation  ;  the  character  of  the  apparatus  compel- 
ling the  regular  healing  of  the  wound.  Indeed,  I  am  not  sure  but 
that  in  this  way  a  proper  mouth  might  be  made  if  the  strictly  surgi- 
cal part  of  the  manipulation  consisted  only  in  a  simple  incision  to 
enlarge  the  parts  to  a  proper  capacity.  For  in  the  operation  it  can- 
not be  said  that  the  reflection  of  the  mucous  membrane  is  an  abso- 
lute necessity ;  whether  this  membrane  should  be  carried  over  the 
cut  surface  or  not,  we  would  very  soon  have  it  clothed  with  such 
tissue,  or  at  least  with  that  which  would  be  found  sufficiently  analo- 
gous to  fairly  represent  it.  Dr.  Miitter,  in  remarking  on  the  philos- 
ophy of  this  operation,  suggests  that  the  annals  of  modern  surgery 
hardly  afi'ord  an  example  of  greater  ingenuity  than  the  procedure  of 
Dieffenbach.  "  The  great  difficulty,"  he  truly  remarks,  "in  all  these 
cases  arises  from  the  constant  tendency  to  contraction  manifested  by 
the  cicatrix,  which  occasionally  goes  on  to  such  an  extent  that  the 
orifice  of  the  mouth  is  almost  closed.  At  the  first  examination  of 
such  a  deformity,  the  remedy  which  seems  to  promise  most  success," 


554  ORAL  DISEASES  AND   SURGERY. 

says  Dr.  M.,  "is  mechanical  dilatation.  Unfortunately,  this  is  pro- 
ductive of  but  temporary  relief,  and  has  never,  I  believe,  effected  a 
permanent  cure.  Next  to  this  method  comes  incision  of  the  commis- 
sures. We  might  naturally  expect  such  a  course  to  be  sufficient  to 
effect  the  ends  desired;  and  in  all  probal:)ility  this  would  be  the  case, 
could  we  by  any  means  prevent  reunion  of  the  edges  of  our  incisions. 
But  this,  it  would  appear  from  statements  of  the  best  authorities, 
has  hitherto  been  impossible  ;  for,  notwithstanding  the  introduction 
of  tents,  leaves  of  sheet-lead,  cerate  cloth,  etc.  between  the  lips  of 
the  wounds,  adhesions,  more  or  less  complete,  are  sure  to  take  place." 

The  instrument  which  I  suggest  will,  I  think,  meet  indications 
which  the  appliances  heretofore  used  have  not  been  able  to  meet. 
A  tent,  or  cerate  cloth,  or  strip  of  easily  yielding  sheet-lead  might 
not  resist  the  great  contractile  force  existing  in  these  conditions ; 
something  fixed  and  immovable  is  required.  One  would  not  be 
willing  to  trust  to  a  less  resisting  body  than  the  catheter,  after 
urethral  section.  I  do  believe  that  an  instrument  such  as  is  here 
figured,  if  properly  constructed  and  justly  employed,  will  as  certainly 
give  a  perfect  cure  as  that  any  indication  may  be  met  with  a  proper 
remedy  at  hand.  It  will  be  found  reliable  if  there  is  truth  in  sur- 
gical principles.  It  might  be  asked,  "  What  need  of  such  appliances, 
if  Dieffenbach's  operation  will  effect  a  cure  ?"  Unfortunately,  Dief- 
fenbach's  manipulations  cannot  in  all  cases  be  carried  out.  If  the 
mucous  membrane,  for  example,  participates  in  the  lesion,  the  oper- 
ation cannot  be  successfully  performed.  Or  who  can  say  that  flaps 
of  mucous  membrane,  however  nicely  approximated  with  the  skin, 
will  unite  ?  There  are  several  things  which  may  come  between  the 
surgeon  and  success.  There  are,  at  least,  cases  which  Dieffenbach's 
nice  operation  will  not  cure. 

It  seems  to  me  the  means  suggested  will  cure  them. 

The  following  is  an  instructive  case,  reported  by  Dr.  C.  A. 
Hart : 

"  Mary  Grabau,  aged  ten  years,  was  brought  to  me  by  her  mother, 
on  May  10th,  and  presented  the  following  appearance:  countenance 
blanched,  body  thin  and  emaciated,  the  features  having  a  pinched 
expression,  and  the  buccal  orifice  contracted  to  such  an  extent  as  to 
only  admit  the  little  finger  over  the  first  joint  with  the  employment 
of  an  effort.  The  angles  were  occupied  by  dense  cicatrices,  extend- 
ing on  to  the  cheeks  and  chin.  The  cheeks  were  also  extensively 
adherent  to  the  superior  maxilla.  The  transverse  diameter  of  the 
mouth  was  nine  lines. 


OPERATIONS   UPON   THE  LIPS  AND    CHEEK.      ^^^3 

"  The  histoiy  of  the  case  rendered  by  the  mother  was  as  follows: 
at  the  age  of  three  years,  the  child  was  attacked  by  scarlet  fever,' 
and  during  the  disease  the  sloughing  of  the  fauces  and  cheeks  was 
very  extensive,  perforations  of  the  cheeks  occurring  at  five  diilerent 
sites.  The  angles  of  the  mouth  were  also  badly  involved.  Duriu"- 
convalescence,  the  perforations  of  the  cheeks  healed,  and  the  cicatriza- 
tion of  the  angles  of  the  mouth  closed  the  orifice  to  about  one-half 
the  normal  size.  After  the  recovery  of  her  strength,  an  operation 
was  desired  for  the  relief  of  her  condition,  and  performed  by  Dr.  E., 
of  this  city ;  the  method  being  a  simple  incision  from  each  angle  of 
the  mouth,  with  cold-water  dressings  applied  over  the  raw  surfaces. 

"  The  result  of  this  was  of  course  nil,  with  the  exception  that  the 
mouth  became  even  smaller  than  before,  so  that  it  was  with  dif- 
ficulty that  she  could  take  her  food  with  an  ordinary-sized  teaspoon. 
This  was  followed  in  the  same  year  by  two  other  operations,  whose 
only  results  were  retrogressions;  but  what  methods  were  employed 
it  was  impossible  to  discover. 

"  The  impression  conveyed  upon  seeing  the  case  was  that  much 
could  be  attempted,  and  but  little  hoped  for,  though  her  condition 
was  one  to  command  sympathy  and  demand  an  effort  for  ameliora- 
tion. Before  proceeding  to  any  operation,  Dr.  G.  Ceccarini  was 
called  in  consultation,  and  the  following  method  agreed  upon, 
which,  with  his  and  Prof.  B.  I.  Raphael's  assistance,  I  performed 
on  May  26th.  The  patient  having  been  placed  upon  the  table 
and  brought  under  the  influence  of  chloroform,  the  little  finger  was 
forced  into  the  mouth,  to  extend  the  cheek,  and  a  very  delicate 
scalpel  passed  from  the  angle  of  the  mouth,  horizontally,  between 
the  tissues  of  the  lip,  to  the  extent  of  about  three-fourths  of  an  inch; 
the  point  of  the  blade  was  then  carried  up,  about  five  lines,  by  de- 
pressing the  handle,  and  then  made  to  cut  obliquely  into  the  cavity 
of  the  mouth,  and,  in  this  position,  gradually  drawn  toward  the 
point  of  entrance — thus  forming  a  flap  from  the  inside  of  the  upper 
Up),  lined  with  mucous  membrane. 

"  The  second  step  consisted  in  extending  the  angles  of  the  mouth 
about  three-fourths  of  an  inch,  by  incising  the  skin  and  other  tissues, 
anterior  to  the  first  point  of  entrance  of  the  knife. 

"The  above-described  procedure  was  observed  upon  the  opposite 
side  of  the  mouth,  and  with  much  greater  ease,  as  the  enlargement 
of  one  side  afforded  more  space  for  manipulation. 

"  The  third  step  consisted  in  rolling  the  flaps  which  were  formed 
by  the  first  steps  on  each  side  of  the  mouth,  over  the  raw  surface  of 


556  ORAL  DISEASES  AND   SURGERY. 

the  new  lower  lip,  from  the  situations  of  the  old  angles  to  the  new 
ones,  and  retaining  them  in  situ  by  several  points  of  silk  sutures, 
thus  bringing  two  raw  surfaces  into  apposition,  and  giving  a  crim- 
son mucous  border  to  the  lip.  At  no  period  of  the  operation  was 
the  hemorrhage  sufficient  to  require  the  aid  of  a  ligature  for  its 
arrest,  the  coronary  arteries  both  having  been  obliterated,  either  by 
the  disease  or  the  previous  operations.  The  primary  dressing  con- 
sisted of  cloths  wet  with  tepid  water,  and  instructions  were  given 
to  keep  the  parts  warm  to  avoid  sloughing  of  the  flaps;  ordered 
morphia3  sulph.  gr.  ^  to  be  given  in  about  an  hour. 

"  May  2Tth.  Mouth  considerably  swollen ;  with  high  traumatic 
fever  ;  ordered  appropriate  remedies. 

"  May  28th.  Fever  much  decreased;  has  slept  well,  appetite  good; 
the  edges  of  the  wounds  appear  to  be  united. 

"May  29th.  Condition  much  improved;  has  been  playing  about 
the  room. 

"May  30th.  The  union  being  thoroughly  established,  the  sutures 
were  all  removed. 

"May  31st  A  slight  ulceration  began  on  the  left  side  of  the 
mouth,  which  threatened  to  destroy  the  new  lip,  but  fortunately  ex- 
tended into  the  cheek ;  this  was  controlled  by  the  local  application 
of  a  solution  of  tannin  and  glycerin.  After  this  the  case  progressed 
favorably  to  convalescence. 

"  In  the  method  here  reported  there  is  no  loss  of  substance,  as  in 
the  method  of  M.  Dieffenbach,  and  a  p)erfect  lower  lip  is  formed, 
the  lower  lip  presenting  about  the  same  appearance  as  after  the 
method  of  M.  Serre." 

Plastic  operations  about  the  lips  are  embraced  under  the  general 
name  of  cheiloplasty  ;  those  upon  the  cheeks  are  termed  genioplastic. 

The  necessity  for  such  operations  arises  from  various  caases,  not 
the  least  frequent  of  which  are  sections  made  by  the  knife  of  the 
surgeon.  Reference  to  plate  exhibits  five  cases  ;  the  first  resulting 
from  salivation,  the  second  from  an  ulcer,  the  third,  fourth,  and  fifth 
due  to  operations  for  the  removal  of  cancer. 

The  first  of  these.  Fig.  1,  is  described  as  having  been  a  shocking 
deformity.  The  operation  for  its  relief  was  performed  by  Prof 
Mutter,  the  practice  being  as  follows  :  having  first  extracted  the  use- 
less teeth  of  the  upper  jaw,  which  would  have  prevented  the  proper 
adjustment  of  the  flaps,  or  induced  their  ulceration,  the  edges  of  the 
ulcer  were  freshened,  and  the  integuments  detached  from  the  side  of 


OPERATIONS    UPON  THE  LIPS  AND    CHEEK.     557 

the  jaw.  Two  incisions,  one  above  and  one  below  the  ulcer,  as 
seen  in  the  figure,  were  made,  so  as  to  form  four  flaps.  These  were 
now  allowed  to  fall  together,  and  were  united  in  the  line  of  the  teeth 
as  far  forward  as  the  natural  angle  of  the  mouth.  The  result  was 
entirely  satisfactory. 

In  studying  this  case,  the  reader  will  remark  that  while  the  mode 
of  section,  or  making  the  flaps,  most  happily  meets  the  indications 
so  far  as  filling  up  the  seat  of  the  original  lost  tissue  is  concerned, 
yet  that  this  is  only  done  by  making  two  other  defects,  one  above,' 
the  other  below.  Such  defects,  however,  prove,  in  healthy  tissue, 
of  not  so  much  consequence ;  granulations,  quickly  springing  from 
the  whole  circumference  of  such  wounds,  supply  the  lost  tissue  :  in- 
deed,  in  my  own  experience  I  have  found,  as  a  rule,  that  the  tend- 
ency in  these  fresh  parts  is  to  so  rapid  a  granulation  and  cicatriza- 
tion that  frequently  the  line  of  the  artificial  union  is  torn  apart. 

Fig.  1  may  be  studied  from  another  stand-point.  In  a  case  oper- 
ated on  by  myself,  very  similar  to  the  drawing,  where  the  neighbor- 
ing tissues  were  loose  and  free  in  character,  I  succeeded  in  effecting 
an  admirable  cure  by  simply  dissecting  the  parts  from  the  bone, 
freshening  the  edges,  and  uniting  them  by  the  ordinary  hare-lip  pin, 
supporting  the  whole  by  straps  of  adhesive  plaster  passed  from  be- 
neath the  jaw  to  the  side  of  the  head ;  the  parts  at  first  looked  very 
much  stretched,  but  soon  accommodated  themselves. 

Still  another  mode  of  performing  such  operations  is  after  the  manner 
of  Taliacotius.  Freshening  the  edges  as  before,  map  out,  by  means 
of  a  piece  of  card-paper,  the  size  of  a  flap  required  to  fill  up  the  gap; 
next  lay  this  upon  the  arm,  and,  dissecting  from  the  integuments  its 
size,  supported  by  a  pedicel,  fix  it  in  the  break  by  means  of  stitches 
of  the  interrupted  suture.  To  do  this,  the  arm  is  to  be  brought  over 
the  head,  and  thus  supported  until  union  is  secured,  when  the  pedi- 
cel is  to  be  detached,  and  the  parts  trimmed  to  suit. 

Subfig.  2,  constituting  a  second  study,  represents  an  operation  per- 
formed by  Mott  for  the  relief  of  an  anchylosis  of  the  jaw  dependent 
on  cicatrization  of  the  mouth  with  the  restoration  of  a  part  of  the 
cheek.  1,  exhibits  cicatrix  arising  from  an  ulcer.  This  was  entirely 
excised,  leaving  an  opening  in  the  cheek.  2,  tongue-shaped  flap  cut 
to  fill  up  the  opening  by  being  rotated  upon  its  base. 

Subfig.  3  represents  an  operation  performed  by  Prof.  Pancoast  for 
the  removal  of  an  extensive  cancer,  and  the  formation  of  a  new  lower 
lip.  The  cancer  is  shown  as  circumscribed  by  a  curvilinear  cut. 
A  vertical  incision  in  the  median  line  of  the  chin  extended  from  the 


658  ORAL  DISEASES  AND  SURGEBT. 

curvilinear  cut  iiearh"  to  the  os  hyoides,  and  another,  which  was  hor- 
izontal and  parallel,  to  the  base  of  the  lower  jaw,  formed  four  flaps. 
The  angles  of  the  flaps  being  removed,  the  upper  flaps  (1,  2)  were 
raised  to  the  proper  level,  and  united  by  the  twisted  suture  on  the 
median  line,  when  the  lower  flaps  (3,  4)  were  also  united  on  the 
median  line  so  aato  cover  the  front  of  the  chin. 

Sul)fig.  4  represents  a  similar  case,  treated  by  the  operation  of 
Chopart.  The  lines  show  the  idea  of  the  incisions.  2,  4,  circum- 
scribe the  disease.  1,  5,  3,  6,  show  vertical  cuts.  The  diseased  part, 
all  above  2,  4,  being  removed,  the  integuments  are  loosened  from  the 
lower  jaw,  and  simph^  lifted  up,  being  retained  in  the  new  position 
by  hare-lip  pins,  or  other  convenient  form  of  suture.  This  operation 
occasionally  answers  very  well ;  in  certain  instances,  however,  where, 
for  example,  it  has  been  necessary  to  stretch  the  parts,  much  cica- 
tricial evulsion  is  apt  to  occur. 

Subfig.  5  represents  the  same  position  of  the  disease,  treated 
after  the  manner  of  Lallemand.  1,  the  remaining  portion  of  the  lip, 
which  is  to  be  drawn  over  to  the  angle  of  the  mouth  at  2.  A  flap, 
formed  of  the  integuments  of  the  neck,  having  been  dissected  off,  is 
shown  as  being  partially  rotated  on  its  base,  and  about  to  be  carried 
up  to  cover  the  deficiency.  The  wound  on  the  neck  may  either  be 
approximated  at  its  edges,  or  left  to  heal  by  granulation. 

In  epithelial  cancers  quite  as  large  as  those  represented  in  Figs. 
3  and  4,  I  have  succeeded  in  securing  the  most  perfect  cures  by 
practicing  the  operation  of  Malgaigne.  This  consists  in  removing 
the  diseased  mass  by  a  simple  T-incision ;  the  angles  of  the  mouth 
are  next  enlarged  by  horizontal  cuts,  and  the  V  drawn  together  and 
united  in  the  middle  line  of  the  face.  In  my  own  cases  I  have  al- 
ways placed  a  pin  at  each  corner  of  the  mouth  ;  as  the  result  of  this, 
some  little  puckering  is  produced,  but,  in  return,  it  eases  the  strain 
on  the  middle  line,  and  itself  disappears  after  a  very  few  months. 

Plate  XI.  is  one  of  the  most  valuable  presented  by  Professor 
Smith  in  his  System  of  Sui'gery,  representing  a  combined  operation 
in  rhino-cheiloplasty,  with  the  original  appearance  of  the  patient,  the 
steps  of  an  operation  devised  and  executed  by  Professor  Pancoast, 
and  the  result  obtained  as  exhibited  by  an  accurate  likeness  of  the 
patient  taken  sixteen  months  after  the  operation. 

History  of  the  Case. — The  history  of  this  case,  which  will  serve 
as  a  type  and  study  of  similar  cases,  is  thus  described  by  Professor 
Smith.  "A  man  aged  fifty-three  had  lost  all  the  soft  parts  of  the  nose 
and  whole  of  the  upper  lip,  from  the  commissures  of  the  mouth  to  the 


PLATE    XI. 

RHINOPLASTIC   AND   CHEILOPLASTIC   OPERATIONS. 

Fig.  1.— Appearance  of  patient  prior  to  the  operations  of  Cheiloplasty  and 
Ehinoplasty. — After  Pancoast. 

Fig.  2.— View  of  his  face  with  the  chin  depressed.  The  mouth,  being  con- 
tracted into  a  rigid  orifice,  was  enlarged  laterallj'  by  the  stomato- 
plastic  operation  of  Dieffenbach  for  atresia  oris,  after  which  two 
flaps  were  made,  as  marked  in  the  lines  upon  the  cheeks,  so  as  to 
form  the  upper  lip. — After  Pancoast. 

Fig.  3. — Appearance  of  his  face  after  this  operation,  showing  the  position 
of  the  sutures  and  the  improvement  in  the  mouth. — After  Pancoast. 

Fig.  4. — Shows  the  steps  of  the  Khinoplastic  operation  performed  upon  him 
subsequently.  The  edges  of  the  nasal  cavity  being  freshened  by  a 
grooved  incision,  the  outline  of  the  new  nose  was  marked  on  the 
forehead  before  cutting  the  flap.  The  dots  indicate  the  position 
of  the  sutures. — After  Pancoast. 

Fig.  5. — The  wound  in  the  forehead  being  closed  by  the  hare-lip  sutures,  the 
flap  was  reverted,  and  attached  in  the  groove  on  the  edge  of  the 
nasal  cavity  by  three  stitches  of  the  interrupted  suture,  which 
were  tied  over  little  rolls  of  adhesive  plaster,  after  Graefe's  method. 
The  edge  of  the  septum  is  also  attached  to  the  upper  lip.  The  twist 
in  the  pedicel  is  seen  in  the  root  of  the  nose. — After  Pancoast. 

Fig.  6. — An  accurate  likeness  of  patient,  sixteen  months  after  the  opera- 
tion.— After  Pancoast. 

(559) 


I 


560  ORAL  DISEASES  AND  SURGERY. 

canine  fossa  of  each  side,  as  well  as  the  septum  navium  and  the 
turbinated  bones,  the  cavities  of  the  antra  Highmorianum  and  of 
the  sphenoidal  sinuses  being  exposed.  His  appearance  with  his 
mouth  closed  is  shown  in  Fig.  1.  The  mouth,  when  opened,  pre- 
sented a  rigid  circular  orifice  three-fourths  of  an  inch  in  diameter. 

"  Operation  of  Pancoast. — The  mouth  being  widened  after 
Dieffenbach's  method  (see  description  on  previous  page),  the  free 
surface  of  the  gum  was  freshened,  and  an  incision  was  then  made 
obliquely  upward  and  outward  for  a  quarter  of  an  inch  from  the  point 
where  the  gum  was  covered  by  integuments,  and  from  the  end  of 
this  another  cut  was  made  for  about  the  same  distance,  nearly 
parallel  with  the  incisions  for  widening  the  mouth,  but  inclined  a 
little  downward.  The  cheeks  being  now  loosened  from  the  gum 
and  malar  bone  by  incisions  on  the  side  of  the  mouth,  the  flap  of 
skin  and  subcutaneous  fatty  matter  was  raised  from  the  surface  of 
the  muscle  by  beginning  the  dissection  at  the  angle  next  the  nose, 
Plate  XL  Fig.  2. 

"  The  arterial  branches,  which  were  divided,  having  been  twisted, 
the  flaps  were  drawn  downward  and  forward  over  the  raw  surface 
of  the  gum  and  fastened  together  with  the  hare-lip  suture,  Plate  XI. 
Fig.  3,  the  inner  edge  of  the  rotated  flaps  being  thus  united  in  the 
middle  line  of  the  lip.  The  face  being  then  dressed  with  lint  wet 
with  lead-water  and  laudanum,  the  patient  recovered  in  about  two 
tnonths.     The  nose  was  subsequently  formed  as  follows : 

"  The  hair  being  shaved  from  the  temple  and  forehead,  the  nasal 
orifices  closed  with  lint  to  prevent  the  entrance  of  blood,  and  the 
patient  lying  down  with  the  head  supported  by  a  pillow,  a  flap  was 
raised  from  the  forehead,  as  shown  in  Plate  XI.  Fig.  4,  the  skin  being 
divided  at  a  single  sweep  of  the  knife,  the  blade  of  which  was  in- 
clined outward  so  as  to  cut  a  beveled  edge.  The  apex  of  the  flap, 
which  was  about  five-eighths  of  an  inch  wide,  rested  between  the 
eyebrows,  and  the  tongue-like  portion  which  was  to  form  the  columna 
nasi  extended  up  into  the  scalp.  The  base  of  the  flap  was  nearly 
three  inches  wide,  in  order  to  allow  for  its  subsequent  contraction. 
The  flap,  after  being  dissected  up,  was  then  turned  down  on  the  left 
side  and  wrapped  in  linen,  while  the  wound  in  the  forehead  was 
closed  by  four  interrupted  sutures,  after  which  the  flap  was  applied 
to  the  freshened  edges  of  the  new  lip  and  gums,  the  whole  Ijeing 
held  in  position  by  the  plastic  suture  before  described,  and  tied  over 
rolls  of  adhesive  plaster,  as  in  Grsefe's  method,  Plate  XI.  Fig.  5. 
Union  having  occurred,  the  pedicel  of  the  flap  was  divided,  five 


OPERATIONS    UPON  THE  LIPS  AND    CHEEK.      561 

weeks  subsequently,  by  passing  a  director  under  It,  after  which  it 
was  smoothly  fitted  down  to  the  roots  of  the  ossa  nasi,  in  a  cavity 
which  was  made  for  its  reception  by  excising  a  portion  of  the  sub- 
jacent integuments.  By  the  twelfth  day  union  was  perfect,  and  the 
patient  left  the  hospital  so  much  improved  that,  sixteen'  months 
subsequently,  his  likeness  was  taken,  a^  represented  on  Plate  XI 
Fig.  6." 


36 


CHAPTER    XXXVII. 

THE   TONGUE   AND   ITS   DISEASES. 

Whether  from  infrequency  of  disease  in  this  organ,  or  the 
diflBculty  of  expressing  its  pathological  phenomena,  we  find  very 
little  which  might  be  called  systematic,  that  has  been  written  upon 
the  subject. 

Of  medical  diseases  the  tongue  has  long  been  esteemed  a  reliable 
sentinel:  hence,  many  and  varied  are  its  functional  derangements 
and  expressions.  To  term,  however,  such  derangements  disease 
could  not  by  any  means  be  proper,  the  sympathetic  relationship 
being  evident  to  the  most  superficial  of  observers. 

Of  organic,  or  surgical  diseases,  the  tongue  has  seemed  to  me  to 
have  its  full  share.  These  diseases  are  of  a  twofold  relation:  local, 
as  reference  is  had  to  some  direct  cause  demanding  only  local  at- 
tention ;  indirect,  as  constitutional  ofi'ense  is  the  agent  against  which 
a  treatment  is  to  be  directed. 

Of  local  injuries,  we  may  refer  to  ulcers  caused  by  jagged  and 
projecting  teeth-roots,  to  cuts  and  contusions  from  falls  and  blows, 
to  bites  inflicted  under  vai'ious  circumstances  by  the  teeth,  to  papu- 
lar hypertrophies,  to  epithelial  indurations  and  ulcerations,  to  stings 
from  insects  in  fruit-season,  to  burns,  scalds,  the  incautious  or  acci- 
dental mastication  of  acrid  or  irritating  substances,  to  glossitis,  from 
the  excessive  use  of  tobacco,  from  operations  performed  on  neigh- 
boring parts,  from  mustard  administered  in  strength,  in  necessity 
for  sudden  emesis,  etc. 

Of  associate  or  constitutional  diseases,  we  may  mention  promi- 
nently the  syphilitic  and  mercurial  impressions  appearing  in  the 
form  of  acute  or  chronic  inflammations,  indurations,  fissures,  ulcers, 
and  cysts.  Malignant  diseases,  particularly  scirrhus,  have  here 
also  not  unfrequently  a  first  expression. 

"In  drawing  inferences,"  says  Dr.  Wood,  "from  the  condition  of 
this  organ,  it  is  important  to  know  whether  the  appearances  it  may 
present  are  the  result  of  local  disease  in  the  mouth,  or  of  the  sym- 
pathies which  connect  it  with  other  parts  of  the  system.  In  general, 
(562) 


THE   TONGUE  AND   ITS  DISEASES. 


563 


there  is  little  difficulty  in  coming  to  a  correct  conclusion  upon  this 
point :  it  is  only  necessary  that  the  attention  should  be  directed  to- 
ward it.  This  organ,"  continues  Professor  Wood,  "  seems  to  have 
been  designed  as  an  index,  to  the  eye  as  well  as  to  the  ear,  of  the 
state  of  the  system ;  so  numerous  and  diversified  are  the  morbid 
affections  which  modify  its  healthy  appearance.  It  not  only  par- 
ticipates in  all  general  derangements  of  the  whole  system,  servin"- 
as  one  of  the  surest  guides  to  a  correct  judgment  in  relation  to  the 
degree,  progress,  and  precise  stage  of  the  disease,  but  especially 
also  sympathizes  with  the  different  parts  of  the  digestive  tube,  at 
one  extremity  of  which  it  is  placed. 

"  The  bulk  of  the  tongue  may  be  increased  or  diminished.  Its 
enlargement,  when  not  so  considerable  as  to  be  very  obvious,  may 
often  be  known  by  the  appearance  of  indentations  on  its  sides,  made 
by  the  pressure  of  the  teeth.  This  is  occasionally  one  of  the  first 
■  signs  of  the  mercurial  influence.  Its  contraction,  when  not  the  mere 
efTect  of  dryness,  is  usually  the  result  of  a  diminished  supply  of 
blood,  and  indicates  either  a  general  deficiency  of  the  circulating 
fluid,  or  great  feebleness  of  the  heart's  action.  Like  every  other 
part  naturally  moist,  it  shrinks  by  drying;  and,  under  such  cir- 
cumstances, no  general  inference  can  be  deduced  from  its  mere  loss 
of  volume. 

"  Its  color  is  often  greatly  and  significantly  modified.  Morbid  flor- 
lidness  of  the  tongue  is  the  consequence  either  of  the  condition  of 
the  blood,  or  of  its  greater  abundance  in  the  organ.  In  the  former 
case,  an  unduly  arterial  ized  state  of  the  mass  of  the  blood  is  indi- 
cated ;  in  the  latter,  either  overexcitement  of  the  circulation  gener- 
ally, or  phlogosis  of  the  stomach.  Redness  of  the  tongue,  not  the 
result  of  local  causes  exclusively,  has  been  supposed  by  some  pa- 
thologists to  be  an  almost  certain  sign  of  gastric  inflammation  or 
irritation.  But  this  is  far  from  being  the  case.  It  is  often  seen 
when  no  evidence  of  gastritis  is  presented,  either  by  the  symptoms 
or  upon  dissection,  and  is  not  unfrequently  absent  when  that  disease 
exists.  Serious  practical  injury  may  result  from  this  error.  The 
red  tongue  can  be  considered  as  having  special  reference  to  the  sto- 
mach, only  when  other  symptoms  point  in  the  same  direction,  and, 
even  then,  is  by  no  means  a  certain  sign.  A  livid  or  purple  color 
of  the  tongue  is  usually  dependent  upon  an  insufficient  aeration  of 
:the  blood,  and  is  a  valuable  sign,  in  connection  with  the  same  color 
[Of  the  lips.  Not  unfrequently  the  tongue  is  morbidly  pale;  and  this 
'  state  is  a  sign  of  deficiency  of  the  blood  in  general,  or  of  its  red  cor- 


564  OFAL  DISEASES  AND  SURGERY. 

pusclos  iu  particular,  or  of  great  prostration  of  the  circulating 
forces. 

"Its  condition  as  to  dryness  and  moisture  is  often  highly  signifi- 
cant. But  caution  is  necessary  not  to  mistake  dryness,  from  tempo- 
rary and  unimportant  causes,  for  that  which  results  from  general 
disease.  In  persons  who  sleep  habitually  with  their  mouths  open, 
the  tongue  is  apt  to  be  dry  in  the  morning ;  and  the  same  cause 
often  produces  the  same  effect  in  sickness.  On  visiting  a  patient,  we 
find  the  tongue  unexpectedly  dry,  and  begin  to  feel  some  apprehen- 
sion, until  we  learn  that  the  patient  has  been  breathing  for  some  time 
through  the  mouth  alone.  A  stoppage  of  the  nostrils  often  gives 
rise  to  this  phenomenon.  In  all  doubtful  eases,  it  is  only  necessary 
to  request  the  patient  to  close  his  mouth,  and  then  move  the  tongue 
about  so  as  to  moisten  it.  If  he  succeed  satisfactorily,  we  may  con- 
clude that  the  dryness  was  accidental,  and  of  no  account.  Another 
caution  is  requisite ;  to  take  care,  namely,  that  a  really  dry  tongue 
should  not  be  mistaken  for  a  moist  one,  in  consequence  of  the  patient 
having  recently  taken  a  liquid  into  his  mouth.  Dryness  may  exist 
in  different  degrees,  from  mere  clamminess  to  perfect  aridity.  It  de- 
pends on  a  deficiency  of  saliva,  or  of  mucus,  or  both,  and  indicates 
a  general  tendency  to  diminished  secretion.  It  not  unfrequently 
occurs,  as  a  sympathetic  affection,  in  ulcerative  inflammation  of  the 
small  intestine.  It  affords  sometimes  the  most  important  therapeu- 
tical indications. 

"  The  tempei'atvre  of  the  tongue  serves  as  a  guide  to  that  of  the 
body  generally.  When  cold,  it  evinces,  for  the  most  part,  great 
prostration  of  the  powers  of  life.  It  proves  that  the  process  of  ca- 
lorification is  failing  at  the  very  fountain ;  for  the  breath  must  be 
cool  before  the  tongue  can  become  so  in  any  considerable  degree. 
This  coldness  of  the  tongue  has  been  frequently  noticed  in  severe 
cases  of  epidemic  cholera.  But  we  must  take  care  not  to  confound 
coolness  from  local  causes,  as  from  ice  in  the  mouth,  or  from  the 
patient  having  slept  long  with  the  mouth  open  in  a  cold  atmosphere, 
with  that  proceeding  from  the  state  of  the  system.  Heat  of  the 
tongue,  except  when  arising  from  inflammation  of  the  organ,  may 
be  considered  as  a  sign  of  a  general  elevation  of  temperature. 

"But  the  condition  usually  denominated  a,  furred  tongue  is,  per- 
haps, the  most  valuable  diagnostic  symptom  afforded  by  that  very 
important  little  member.  In  this  state,  the  tongue  is  covered  with 
a  morbid  coating,  which  adheres  so  firmly  that  it  cannot  be  removed 
without  removing  a  portion  of  the  surface  along  with  it.     Occasion- 


THE    TONGUE  AND   ITS  DISEASES. 


565 


ally,  deposits  take  place  from  the  saliva  and  the  mucus  of  the  mouth  • 
but  these  are  easily  removable,  and  must  be  distinguished  from  the 
genuine  fur.  The  latter  proceeds  from  a  secretory  process  of  the 
tongue  itself,  and  seems  to  be  incorporated  with  the  superficial  layer 
of  epithelium.  It  is  almost  always  confined  to  the  upper  surface, 
where  the  structure  of  the  membrane  is  papillary.  Thou"-h  verv 
generally  a  sign  of  disease,  it  is  not  always  so.  Some  persons  have 
a  furred  tongue  habitually,  more  especially  upon  rising  in  the  morn- 
ing; and,  though  in  the  greater  number  of  these  there  is  probably 
some  chronic  disorder  of  digestion,  3-et  in  others  the  health  appears 
to  be  perfect. 

"A  furred  tongue  almost  always  accompanies  fever,  and  is  one  of 
the  most  decided  characteristics  of  that  affection.  Indeed,  when 
considerable  in  degree,  and  not  dependent  upon  stomatitis  of  anv 
kind,  it  may  very  generally  be  regarded  as  a  febrile  symptom.  When 
the  fur  is  ivhite,  thickish,  tolerably  uniform,  and  accompanied  with 
moisture,  it  usually  indicates  an  open,  active  state  of  fever,  in  which, 
though  the  obvious  symptoms  may  possibly  be  violent,  there  is  not 
apt  to  be  any  lurking  mischief,  nor  any  malignant  tendency.  When 
short,  very  adhesive,  and  rather  scanty,  permitting  the  redness  of 
the  tongue  to  appear  through  it,  and  attended  with  some  disposition 
to  dryness,  it  is  often  a  sign  of  a  protracted  and  obstinate  form  of 
fever,  which  is  apt  to  assume  a  low,  nervous,  or  typhoid  form.  A 
yellowish  hue  of  the  fur  is  usually  indicative  of  bilious  disorder, 
being  produced  either  by  the  vomiting  of  bile,  or,  what  is  probably 
much  more  frequent,  by  direct  secretion  from  the  tongue,  consequent 
upon  deficient  secretion  by  the  liver,  or  an  excessive  production  of 
bilious  matter  in  the  blood.  Not  unfrequently,  this  color  of  the 
tongue  is  accompanied  with  a  bitter  taste.  It  is  common  in  mias- 
matic fevers  and  hepatic  diseases.  A  hrou-n  or  black  tongue  is 
usually  indicative  of  a  low  state  of  the  system  and  an  impaired 
condition  of  the  blood.  It  is  owing  to  the  secretion  of  a  dark  mat- 
ter, apparently  identical  with  that  which  collects  about  the  teeth  and 
lips  in  typhous  fevers,  and  probably  consisting  of  blood  modified  in 
its  passage  out  of  the  vessels.  The  same  action  would  seem  to  take 
place  in  the  tongue  as  that  which,  in  the  stomach  and  bowels,  occar 
sions  the  black  discharges  so  common  in  malignant  fevers.  It  may 
depend  on  an  enfeebled  state  of  the  secreting  tissue,  or  a  diseased 
state  of  the  blood,  or  on  both  united.  Very  frequently  this  dark- 
ness of  the  tongue  supervenes  upon  a  previously  white  coating,  and 
indicates  a  deteriorated  state  of  the  vital  forces  and  probably  of  the 


566  ORAL  DISEASES  AND  SURGERY. 

blood.  The  caution  should  be  observed,  not  to  confound  this  discol- 
oration with  that  which  may  proceed  from  accidental  causes,  as  from 
the  chewing  of  liquorice,  tobacco,  burnt  coffee-grains,  etc.  In  many 
instances,  the  white  fur  of  the  tongue  is  modified  by  ?^ed  points, 
which  are  the  tops  of  the  swollen  and  projecting  papillae.  This  ap- 
pearance is  not  uncommon  in  eruptive  febrile  diseases,  especially 
scarlet  fever  and  measles.  When  consequent  upon  a  dyspeptic  state 
of  the  stomach,  the  fur  is  most  copious  in  the  morning  before  break- 
fast. In  some  persons,  emptiness  of  the  stomach  is  said  always  to 
induce  this  state  of  the  tongue. 

"  The  manner  in  which  a  furred  tongue  becomes  clean  affords  valu- 
able indications.  When  the  fur  slowly  recedes  from  the  tip  and 
edges,  thinning  gradually  as  it  retires,  it  intimates  a  favorable  con- 
valescence. A  portion  of  fur  often  lingers  near  the  root  of  the  tongue, 
long  after  the  disease  has  given  way.  In  another  mode  of  cleaning, 
the  fur  loosens  and  separates  in  flakes,  often  beginning  at  the  middle 
or  near  the  root,  sometimes  in  large  patches,  or  over  almost  the 
whole  tongue  at  once,  leaving  a  smooth,  red,  glossy  surface,  as 
though  the  papillary  structure  had  been  lost.  In  such  cases,  if  acute, 
and  if  the  tongue  remains  moist,  convalescence  almost  always  takes 
place,  though  usually  tedious,  and  sometimes  very  lingering.  In 
threatening  fevers,  it  is  very  desirable  to  witness  this  phenomenon ; 
and,  as  it  is  often  preceded  by  a  feeling  of  soreness  in  the  fauces, 
this  may  be  considered,  when  it  occurs  in  such  cases,  as  an  auspi- 
cious circumstance.  Much  stress  was  laid  upon  this  as  a  prognostic 
symptom  by  the  late  Dr.  Joseph  Parrish,  of  Philadelphia.  Some- 
times the  fur  recurs  once  and  again,  before  it  ultimately  disappears ; 
and  weeks  and  even  mouths  are  occasionally  consumed  in  the  strug- 
gling and  apparently  uncertain  advance  of  the  system  toward  health. 
In  less  favorable  cases,  the  tongue,  after  having  commenced  the  pro- 
cess of  cleaning,  as  just  described,  or  even  after  completing  it,  in- 
stead of  continuing  moist,  becomes  as  dry  as  a  chip,  with  an  aggra- 
vation of  all  the  symptoms,  and  no  little  increase  of  danger.  The 
indication  is  still  more  unfavorable  when,  in  addition  to  its  dryness, 
the  surface  becomes  gashed,  chapped,  or  fissured,  or  exhibits  a  rough, 
scaly  appeai-ance. 

"  This  smooth,  red,  and  glossy  state  of  the  tongue,  sometimes  with 
moisture  and  sometimes  with  dryness,  is  not  uncommon  in  chronic 
diseases,  in  which  it  is  generally  a  bad  sign,  and  is  supposed  to  indi- 
cate serious  organic  derangement  of  the  alimentary  mucous  mem- 
brane.    A  still  worse  condition,  however,  is  an  aphthous  state  of 


THE   TONGUE  AND  ITS  DISEASES.  567 

the  tongue,  which  is  apt  to  come  on  in  the  advanced  stages  of  chronic 
diseases,  and  is  generally  to  be  received,  under  these  circumstances, 
as  a  fatal  sign,  though  of  itself,  and  occurring  in  ordinary  health,  it 
is  in  no  degree  alarming. 

"A  loss  or  depraimtion  of  taste  is  not  uncommon,  and  is  generallv 
of  little  consequence,  depending  upon  a  mere  derangement  of  the 
surface  which  receives  the  gustatory  impressions.  But  when  of  a 
paralytic  nature  it  is  much  more  serious,  as  it  generally  indicates 
disease  within  the  encephalon. 

"The  only  other  point  requiring  consideration  refers  to  the  move- 
ments of  the  tongue.  When,  in  acute  febrile  diseases,  these  are  not 
under  the  control  of  the  patient,  when  upon  being  requested  to  pro- 
trude his  tongue  he  is  unable  to  do  so,  or  when  the  organ  trembles 
much  in  the  attempt,  the  symptom  is  exceedingly  unfavorable,  indi- 
cating either  great  prostration,  or  dangerous  cerebral  disease.  Of 
similar  unfavorable  prognostication,  under  the  same  circumstances, 
is  the  occurrence  of  a  difficult  and  hesitating  utterance,  like  stam- 
mering. The  inclination  of  the  tongue  towards  one  side,  when  pro- 
truded, usually  indicates  palsy,  and  is  one  of  the  common  attendants 
upon  hemiplegia." 

With  these  almost  exhaustive  observations  by  Professor  Wood  are 
to  be  associated  and  noticed  the  facts  that  in  some  nervous,  irritable 
persons  the  tongue  is  found  habitually  furred,  yet  without  any  symp- 
toms of  gastric  or  other  derangements.  Some  persons  get  furred 
tongue  the  moment  their  stomachs  are  empty ;  others  have  their 
tongues  coated  always  after  a  meal  and  while  digestion  is  going  on, 
the  coating  passing  away  as  the  function  ceases.  Mental  and  moral 
emotions  have  a  most  decided  influence.  Dr.  Wright,  in  one  of  his 
clinical  lectures,  mentions  the  following  striking  illustration  : 

"  In  calling  upon  a  certain  patient,"  says  this  gentleman,  "  the 
first  thing  I  did  was  to  look  at  his  tongue.  I  found  it  as  usual,  very 
pale,  flabby,  and  moist,  but  without  any  coating.  After  having 
made  other  necessary  inquiries,  I  was  informed  by  my  patient  that 
his  heart,  which  had  long  been  disturbed  by  mental  emotions,  had 
on  the  previous  evening  beat  with  unusual  violence  and  irregularity. 
On  my  asking  if  he  could  account  for  it,  he  told  me  that  he  had  just 
then  received  the  distressing  intelligence  that  an  uncle  from  whom  he 
expected  a  competency,  had  not  left  him  a  shilling.  This  pitiable 
tale,  told  with  much  earnestness  and  visible  feeling,  occupied  little 
more  than  twenty  minutes.  At  the  end  of  that  time  I  again  looked 
at  his  tongue,  and  found  it  coated  with  a  thick,  white  fur." 


568  ORAL  DISEASES  AND  SURGERY. 

It  is,  however,  not  with  functional  expressions  of  the  organ,  but 
with  diseases  localized  in  it,  that  the  surgeon  has  to  treat.  These 
diseases,  by  the  review  made  of  sympathetic  disorders,  we  are  now 
prepared  to  consider. 

The  most  frequent  disease  of  the  tongue  with  which  I  have  met 
is  syphilis.  Syphilitic  ulcers,  the  most  common  of  the  manifesta- 
tions, appear  on  any  part  of  the  organ,  but  are  most  common  to  the 
sides  and  under  surface.  Such  ulcers  are,  in  my  experience,  invari- 
ably accompanied  by  associations  of  its  origin, — psoriasis  on  the 
body,  nodes,  falling  of  the  hair,  lymphatic  induration  of  the  posterior 
cervical  ganglia.  A  syphilitic  ulcer  on  the  tongue  has  the  appear- 
ance of  chancre,  hard  or  soft :  we  meet  with  them  where  the  ulcera- 
tion is  quite  deep  and  the  edges  heavily  indurated.  Again,  where 
there  is  neither  excavation  nor  induration,  we  know,  however,  that 
they  are  venereal  from  the  associations. 

A  second  form  of  syphilitic  disease  of  the  tongue  is  observed  in 
the  induration  and  hypertrophy  of  circumscribed  patches  of  mucous 
membrane.  The  induration  in  these  cases  is  so  markedly  localized, 
that,  if  it  were  not  for  their  varying  locations, — being  always,  how- 
ever, on  the  dorsum, — one  might  readily  believe  them  to  be  enlarged 
circumvallate  papillae  ;  the  patches  are  quite  as  large  as  a  dime  piece, 
are  elevated,  and  are  as  isolated  as  one  sees  a  fungiform  wart.  I 
have  seen  two  such  patches  on  the  dorsum  of  a  tongue,  and  at  the 
same  time  a  large  ulcer  on  its  under  surface. 

Cracks  and  fissures  are  other  syphilitic  indications  met  with  on 
the  tongue.  It  may  happen  in  some  instances  that  these  fissures  are 
so  deep  as  to  seem  to  divide  the  organ  into  a  number  of  parts ;  they 
always,  so  far  as  I  have  observed,  run  lengthwise.  These  fissures 
are  at  times  unbearably  sore,  denying  the  patient  comfort  either  in 
eating  or  in  rest. 

Indurations  of  the  nmcous  membrane  of  the  sides  of  the  tongue  are 
occasionally  observed,  or  it  may  be  that  a  general  thickening  exists, 
or,  indeed,  that  the  whole  organ  is  indurated.  In  this  latter  con- 
dition the  disease  has  sometimes  been  mistaken  for  cancer ;  but 
such  an  error  could  arise  only  from  a  failure  to  observe  the  associa- 
tions of  the  case. 

Sometimes  the  dorsum  presents  red  patches,  the  result,  evidently, 
of  a  loss  of  the  epithelial  covering.  These  patches  are  perfectly 
smooth,  not  ulcerated,  but  are  painfully  sensitive  to  hot  or  cold 
impressions.  I  have  met  with  this  condition  where  the  dorsum 
seemed  literally  skinned. 


THE   TONGUE  AND    ITS  DISEASES.  569 

The  treatment  of  syphilis  in  the  tongue  has,  with  one  special  ex- 
ception, the  twofold  signification  of  constitutional  and  local,— the 
exception  being  that  of  chancre.  It  has  without  doubt  occurred  that 
a  man  has  gotten  a  chancre  upon  his  tongue.  Mercury,  in  some  of 
its  various  forms,  seems  to  be  looked  upon  by  most  practitioners  as 
having  in  this  direction  something  specific  in  its  nature;  without 
doubt,  however,  it  is  a  greatly  abused  medicine,  and  should  be  used 
with  more  caution  and  judgment  than  generally  characterize  its  ex- 
hibition. 

Where  ulcers  or  other  manifestations  upon  the  tongue  are  second- 
ary in  their  signification,  and  mercury  has  not  been  used  upon  the 
case,  it  is  marvelous  how  at  times,  under  its  influence,  such  mani- 
festations can  be  made  to  disappear.  How  this  medicine  is  to  be 
used  is  perhaps  best  left  to  be  directed  by  the  apparent  requirements 
of  individual  cases.  Of  one  thing,  however,  I  am  sure :  its  best 
effects  are  not  to  be  obtained  by  salivating  the  patient.  Mercury  in 
the  form  of  the  bichloride  is  a  favorite  prescription;  it  may  be  given 
in  doses  of  from  the  tenth  to  the  twentieth  of  a  grain  dissolved  in 
water  or  the  fluid  extract  of  sarsaparilla,  three  times  a  day.  The 
hyd.  c.  creta,  combined  with  Dover's  powder,  is  a  combination 
which  may  be  used  with  benefit  where  dryness  and  other  lack  of 
function  are  found  in  the  skin.  Impression  by  inunction  is  another 
mode  of  exhibiting  the  medicine.  A  lump  of  mercurial  ointment,  the 
size  of  a  large  pea,  may  be  rubbed  into  the  inner  face  of  the  thighs 
night  and  morning.  Calomel  in  quarter-grain  doses,  combined  with 
small  quantities  of  sugar  to  render  it  palatable,  may  be  given  every 
two  or  three  hours,  until  the  patient  remarks  the  coppery  taste. 
Blue  pill,  in  five-grain  doses,  answers  very  well  if  there  is  no  he- 
patic disturbance,  as  manifested  by  gastric  derangement  and  sick- 
headache. 

Of  the  various  mercurial  preparations,  I  think,  however,  the 
preference  will  be  found  to  reside  with  the  bichloride:  in  this  form 
the  impression  of  the  medicine  is  gradually  secured.  If  necessary,  it 
may  be  given  continuously  for  a  month. 

Combined  with  the  mercurials,  it  has  been  my  experience  that 
tonics  are  generally  found  indicated, — a  something  to  counteract  the 
degenerative  tendency  which  appears  to  reside  in  every  dose  of  a 
mercurial  administered.  Iron,  quinine,  gentian,  and  bark  are  excel- 
lent preparations.  A  prescription  which  will  be  found  to  be  a  very 
good  one  is  as  follows: 


I 


570  ORAL   DISEASES  AND  SURGERY. 

R. — Hytlrarg.  bicbl.  gr.  iv  ; 
Elx.  ferri  cinch.  5vi.     M. 
Sio".  A  teaspoonful  three  times  a  day. 

A  second,  admirable  in  cases  associated  with  nervous  disturb- 
ance is  the  combination  with  the  mercurial  of  the  pyrophosphate 

of  iron : 

B. — Hydrarg.  bichl.  gr.  iv  ; 

Syrupus  ferri  pyrophos.  ^vi.     M. 

Sig.  A  teaspoonful  three  times  a  day. 

In  syphilitic  diseases  of  the  tongue,  tertiary  in  its  type,  mercury 
will  seldom  be  found  admissible.  The  system  is  broken  do\vn:  the 
process  of  cure  must  be  one  of  regenerative  repair.  These  are  the 
patients  for  the  sea-shore  and  the  hill-side.  You  will  not  get  them 
well  if  you  cannot  build  them  up. 

Conjoined  with  the  tonic  medication  of  these  cases,  very  ex- 
perienced authorities  commend  the  use  of  the  iodide  of  potassium. 
Whei'e  it  is  thought  desirable  to  use  this  medicine,  ten  grains  as 
a  dose  may  be  given  three  times  a  day.  It  is  most  conveniently 
exhibited  in  water,  or,  if  taste  is  consulted,  in  the  fluid  ext.  of  sar- 
saparilla. 

Tertiary  symptoms,  M.  Ricord  observes,  will  not  inevitably  occur 
in  the  course  of  syphilis,  but  they  are  very  likely  to  do  so  if  the 
treatment  of  the  primary  and  secondary  symptoms  be  not  conducted 
with  the  greatest  care.  As  soon  as  ever  the  tertiary  period  has  set 
in,  mercury  must  be  abandoned,  and  iodide  of  potassium  given. 
Xay,  further,  as  mercury  taken  in  time  may  prevent  or  retard  sec- 
ondary symptoms,  and  so  may  be  regarded  as  a  prophylactic  against 
them,  so  may  iodide  of  potassium  be  regarded  as  a  prophylactic 
against  tertiary  symptoms  ;  and  therefore  M.  Ricord  observes  : 

"To  render  the  treatment  of  secondary  syphilis  complete  and 
rational,  it  should  always  be  followed  by  the  exhibition  of  iodide  of 
potassium.  This  substance  is,  however,  not  only  useless  when  em- 
ployed against  secondary  symptoms  and  those  of  transition,  but  very 
often  hurtful ;  yet,  when  secondaries  have  been  of  long  standing,  it 
may  produce  beneflcial  eifects;  it  is  also  useful  as  an  adjuvant  of 
mercury  in  those  affections  which  in  some  degree  lie  between  the 
secondary  and  strictly  tertiary  manifestations ;  and,  finally,  it  is  in- 
dispensable for  combating  the  symptoms  of  a  decided  tertiary  nature. 
In  order  to  become  well  acquainted  with  the  proper  manner  of  ad- 
ministering the  iodide  of  potassium,  we  should  take  the  trouble  of 


THE    TONGUE  AND   ITS  DISEASES.  571 

studying  its  effects,  independently  of  its  curative  action.  First  let 
us  see  how  it  acts  on  the  skin.  It  may  produce  on  the  cutaneous 
surface  diverse  psydracious  and  acnoid  eruptions.  The  pustules  are 
generally  surrounded  by  a  vividly  red  areola,  and  the  usual  seat  of 
these  eruptions  is  below  the  umbilical  region,  as  the  nates,  thighs, 
etc.,  whereas  the  common  acne  (not  to  mention  its  other  characters) 
is  mostly  situated  in  the  upper  half  of  the  body.  To  these  peculi- 
arities, it  may  be  added  that  the  pustules  will  fall  in  immediately 
the  administration  of  the  iodide  is  interrupted.  Exanthemata,  im- 
petigo, and  lichen  are  very  apt  to  be  produced  by  the  use  of 'this 
salt ;  and  what  you  ought  especially  to  keep  in  mind  is,  that  ecchy- 
mosis,  and  purpura  in  the  inferior  extremities,  are  sometimes  caused 
by  the  action  of  the  iodide  of  potassium.  The  effects  of  the  latter 
on  mucous  membranes  should  also  be  carefully  observed.  It  may 
cause  inflammation  of  the  conjunctiva,  the  submucous  cellular  tis- 
sue lying  under  which  gets  then  infiltrated  and  puffed  up ;  the  eye- 
lids turn  red  and  oedematous,  and,  when  the  inflammation  and  effu- 
sion are  not  arrested,  the  internal  parts  of  the  eye  become  involved 
in  the  affection,  and  photophobia  is  the  result  of  this  state  of  thing.s. 
The  normal  mucous  secretion  is  always  a  little  increased,  but  it  does 
not  take  the  muco-purulent  character,  as  in  the  case  of  catarrhal  oph- 
thalmia, Coryza,  of  a  more  or  less  severe  nature,  often  exists  at  the 
same  time  ;  it  is  preceded  and  accompanied  by  headache,  and  a 
pretty  abundant  mucous  secretion ;  but  this  coryza  never  reaches 
the  suppurative  state  ;  it  never  produces  more  than  a  catarrho-serous 
flux.  These  affections  never  give  rise  to  any  fever,  and  they  disap- 
pear as  soon  as  the  iodide  is  given  up.  This  coiyza  is  an  accident 
which  we  should  not  overlook;  for  it  is  of  importance  to  avoid  it 
when  we  have  to  treat  a  tertiaiy  affection  of  the  nasal  fossae.  As 
for  the  effect  of  the  iodide  on  the  intestinal  canal,  I  have  to  state  that 
persons  enjoying  good  health  can  bear  very  large  doses  of  it ;  I  have 
given  as  much  as  fifteen  drachms  a  day.  M.  Puche  has  often  given 
ten  drachms  per  diem,  after  commencing  with  six ;  and  it  has  been 
noticed  that  it  improves  the  appetite  of  the  persons  who  use  it. 
With  some  patients  a  certain  pleurodynic  sensation,  corresponding 
to  the  cardiac  extremity  of  the  stomach,  is  felt  after  its  ingestion ;  but 
it  never  causes  vomiting.  The  submucous  cellular  tissue  of  the 
stomach  may,  by  the  use  of  this  iodide,  undergo  the  same  modifica- 
tions which  we  have  noticed  the  conjunctiva  to  be  subject  to, — a  sort 
of  hyper-secretion  and  intestinal  ptyalism  takes  place,  and  much  of 
the  fluid  which  ought  to  have  been  secreted  by  the  skin  is  rejected 


572  ORAL  DISEASES  AND  SURGERY. 

by  the  mouth.  This  liquid  has  a  slight  taste  of  iodine ;  it  is  not 
fetid  in  the  least ;  the  gums  are  not  swollen,  and  there  is  no  fetor 
in  the  breath,  as  happens  in  mercurial  ptyalism.  The  same  effect 
may  be  produced  on  the  other  portions  of  the  intestinal  canal ;  the 
patients  are  then  seized  with  abundant  serous  diarrhoea.  The  iodine 
is  eliminated  from  the  system  by  the  kidneys;  half  an  hour  after  the 
ingestion  of  it,  its  presence  may  be  ascertained  in  the  urine,  and  it 
should  be  remembered  that  the  presence  of  iodine  in  the  blood  in- 
creases the  renal  secretion.  I  hav-^e  even  ob,served  a  case  of  poly- 
dipsia which  went  on  ab  long  as  the  iodide  was  used,  but  disap- 
peared when  the  latter  was  discontinued,  and  gradually  sprang  up 
again  as  the  use  of  the  salt  was  resumed. 

"The  effects  of  the  iodide  of  potassium  on  the  circulation  are  of 
a  sedative  kind ;  it  diminishes  the  number  of  arterial  pulsations, 
and  lowers  their  force,  but  they  may  regain  their  normal  standard 
if  the  remedy  act  beneficially  on  the  system  ;  the  same  arterial  en- 
ergy may  also  reappear  when  the  iodide  causes  a  slight  phlegmasia. 
This  salt  is  somewhat  antiplastic;  for  it  has  rather  a  tendency  to 
liquefy  the  blood,  and  may  even  produce  the  peculiar  hemorrhages 
of  purpura.  When  the  effect  of  the  iodide  on  the  nervous  system  is 
carefully  watched,  it  is  found  to  cause  a  certain  excitement  of  the 
nervous  centers,  followed  by  a  little  uncertainty  in  the  movements 
and  in  the  intelligence." 

A  combination  much  employed  by  Sir  Astley  Cooper,  in  cases 
where  the  iodide  of  potassium  seemed  not  to  favor  the  patient,  was 
the  liquor  arsenici  et  hydrargyri  hydriodatis, — Donovan's  solution. 

Concerning  the  local  treatment  of  the  venereal  affections  of  the 
tongue,  with  which,  in  a  work  like  this,  we  would  seem  to  have 
most  to  do,  little  is  to  be  added  outside  of  the  suggestions  offered 
on  other  pages.  The  treatment  is  constitutional :  direct  medication 
is  perhaps  simply  to  be  esteemed  as  palliative.  Lactuca  sativa  five 
ounces,  honey  one  ounce  and  a  half,  and  alum  one  drachm  and  a  half, 
is  a  favorite  gargle  with  Ricord  in  all  these  cases. 

Another  consists  of  a  decoction  of  hemlock,  six  ounces  and  a  half, 
to  bichloride  of  mercury,  three  grains.  From  my  own  experience,  I 
have  suggested  the  use  of  acids  applied  to  the  ulcers  in  cases  where 
the  dyscrasis  has  been  corrected  or  nearly  so.  It  is  surprising  with 
what  rapidity  a  syphilitic  ulcer  will  respond  to  almost  any  of  the 
mineral  acids. 

In  a  bad  case  of  mucous  tubercles  I  once  treated,  I  got  my  patient 
well  by  daily  salt-baths  and  the  local  use  of  quinia  and  iron;  twenty- 


THE    TONGUE  AND   ITS  DISEASES.  573 

five  grains  of  the  former  to  two  drachms  of  the  mm-iatecl  tincture. 
The  tubercles  were  painted  twice  each  day  for  two  months. 

Borax  is  a  soothing  application;  it  may  be  rubbed  with  water 
into  a  cream,  and  thus  be  applied  ad  lib. 

A  species  of  local  specific,  to  be  used  on  the  part  and  rinsed  away 
after  a  few  moments,  is  compounded  as  follows : 

R. — Aqua  destillat.  5ixss  ; 
Ferri  perchl. 
Acid,  citric. 

Acid,  hydrochloric,  aa  Ji-     M. 
This  may  be  repeated  three  or  four  times  in  the  day. 

Fissures  and  fistula  are  sometimes,  in  their  chronic  form,  cauter- 
ized, nitric  acid,  pure  or  dilute,  being  used  for  the  purpose.  In  a 
case  of  long-standing  fissure  of  the  tongue,  I  on  one  occasion  cut 
out  the  induration,  the  patient  making  a  rapid  recovery. 

Chloride  of  zinc,  twenty  grains  to  the  ounce  of  water,  will  be 
found  a  useful  application  in  chronic  syphilitic  conditions,  whether 
of  ulcer,  fistule,  or  fissure. 

Mercurial  enlargement  and  induration  of  the  tongue  is  a  condition 
frequently  demanding  treatment.  One  of  the  first  effects  of  this 
medicine  is  often  seen  in  the  markings  made  upon  the  sides  of  this 
organ  by  an  otherwise  not  observed  swelling  which  has  crowded  it 
against  the  teeth.  The  tongue  tumefied  by  the  impressions  of  calo- 
mel may  become  so  enlarged  as  to  fill  the  whole  mouth.  One  par- 
ticular case  I  recall,  where,  to  prevent  the  patient  from  being  smoth- 
ered, I  was  compelled  to  drag  the  body  forward  over  the  lower  jaw, 
and  thus  fix  it  until  relief  could  be  otherwise  secured. 

Mercurial  ulceration  of  the  tongue  is  another  of  the  offenses  of 
this  medicine.  Such  ulcerations  are  in  appearance  indolent  and  irri- 
table, are  associated  with  similar  conditions  of  the  gums,  and  with 
salivation  :  their  diagnosis  is  very  plainly  marked. 

The  rational  treatment  of  the  mercurial  conditions  refers  to  the 
correction  of  the  local  impressions,  together  with  elimination,  and 
support  applied  to  the  system  at  large.  In  rapid  swellings  of  the 
tongue,  it  may  be  found  necessary  to  resort  to  the  use  of  leeches, 
combined  with  most  marked  derivation.  In  the  case  above  referred 
to,  forty  common  leeches  were  applied  to  the  throat,  the  patient 
was  profusely  sweated,  and  these  applications  were  succeeded  by  a 
saline  cathartic. 

Such  treatment,  combined,  if  the  circulation  is  sthenic,  with  some 


I 


574  ORAL  DISEASES  AND  SURGERY. 

arterial  depressant,  as  digitalis,  aconite,  or  veratrum,  will  commonly 
relieve  from  the  immediate  danger.  Unless,  however,  the  ptyalism 
has  been  acutely  excited,  and  the  subject  is  strong  and  vigorous, 
this  treatment  will  be  succeeded  by  great  lassitude  and  depression ; 
such  depression  is,  however,  a  necessity,  and  has  perhaps  saved 
the  life. 

A  local  treatment  in  cases  of  this  kind  is  simply  palliative  and 
soothing.  The  lactuca  sativa  and  honey,  recommended  in  the  syphi- 
litic sore-mouth,  is  an  excellent  gargle.  Sage  tea,  combined  to  a 
full  saturation  with  chlorate  of  potassa,  is  another  agreeable  applica- 
tion. Common  table-tea  is  very  grateful  to  a  patient.  In  combi- 
nation with  these,  or  any  similar  demulcent  gargle,  I  have  found 
that  great  relief  has  been  derived  from  the  free  exhibition,  internally, 
of  the  bromide  of  potassium. 

R. — Potass,  brom.  5ss ; 
Aqua,  ^viij.     M. 
Sig.  Tablespoonful  repeated  occasionally  as  the  patient  is  nervous. 
Twenty  grains,  as  here  directed,  may  be  prescribed  three  times  a 
day  at  the  least.     I  have  given  eighty  at  a  single  dose. 

The  acute  conditions  of  a  mercurial  glossitis  combated,  the  prac- 
titioner may  find  it  desirable  to  attend  to  the  more  general  require- 
ments of  the  case.  The  system  is  to  be  protected  against  further 
impressions  of  the  agent,  while  at  the  same  time  it  will  generally 
be  found  that  a  present  support  is  demanded.  Chlorate  of  potassa, 
the  antagonist  of  the  mercurials,  has  now  obtained  in  this  direc- 
tion an  almost  universal  use :  it  may  be  administered  in  full  satu- 
ration, in  tablespoonful  doses,  three  or  four  times  a  day.  A  very 
good  way  to  prescribe  this  salt  is  to  order  one  ounce  placed  in  an 
eight-ounce  bottle,  which  is  to  be  kept  filled  with  water  until  all  is 
dissolved.  As  each  dose  is  taken,  the  patient  replaces  it  Avith  fresh 
water. 

In  the  treatment  of  the  mercurial  ulcer,  the  local  applications 
suggested  have  been  various.  Bismuth,  red  bark  and  borax,  in 
equal  proportions,  act  sometimes  very  happily.  Chlorate  of  potassa, 
tannic  acid,  and  glycerin  is  another  excellent  combination.  Solu- 
tions of  sulphate  of  copper  or  zinc,  one  grain  to  the  ounce  of  water, 
are  cleansing  and  stimulating  applications.  Iron,  opium,  chalk- 
powder,  aromatic  powder,  are  all,  in  their  turn  and  place,  useful. 
If  phagedena  intervene  or  threaten,  the  potassio-tartrate  of  iron,  as 
recommended  by  Ricord  in  the  similar  ulcers  of  syphilis,  is  not  to 


THE   TONGUE  AND   ITS  DISEASES.  575 

be  omitted :  it  may  be  used  in  the  strength  of  thirty  grains  to  the 
ounce.  It  should  also  be  administered  internally  in  doses  varyin"- 
from  five  to  ten  grains  repeated  every  two  hours. 

Chronic  phagedena,  which  in  some  degree  associates  itself  more 
or  less  frequently  with  mercurial  ulcers,  is  best  treated  by  the 
potential  cauterants.  Of  these,  a  favorite  is  creasote  :  it  is  to  be  ap- 
plied with  care,  however,  as  it  may  provoke  secondary  inflamma- 
tion. Carbolic  acid  is  a  useful  article,  and  will  sometimes  prove 
very  reliable.  Nitric  acid  is  highly  recommended  by  many  practi- 
tioners :  when  applied,  every  recess  of  the  sore  should  be  burned, 
and  this  should  be  repeated  daily  until  healthy  granulations  are 
provoked. 

SciRRHUS. — Of  the  third  form  of  constitutional  impressions, 
scirrhous  carcinoma  may  now  engage  our  consideration.  This 
scirrhus  of  the  tongue,  from  the  circumstances  of  its  association 
and  position,  is  to  be  assumed  a  necessarily  dangerous,  if  not  fatal, 
disease.  Scirrhus  in  other  parts  may  be  cured  ;  that  is  to  say, 
being  removed,  it  may  not  reappear  in  the  part  of  removal, — although, 
being,  as  is  most  likely,  a  constitutional  condition,  it  is  perhaps  sel- 
dom that  the  disease  is  permanently  destroyed.  That  scirrhous  car- 
cinoma is  not,  however,  at  least  in  its  incipiency,  so  formidable  a 
condition  as  encephaloid,  seems  to  be  the  universal  impression : 
there  is  a  fixedness,  an  apparent  isolation,  about  it,  which  always 
invites  operation. 

Situated  in  the  tongue,  such  isolation  is,  unfortunately,  not  so 
marked  as  when  found  in  other  parts :  it  appears  as  an  induration 
rather  than  as  what  might  be  termed  a  lump,  and  this  induration 
has  not  commonly  a  definite  boundary  to  its  stroma:  hence,  if  re- 
moved by  operation,  one  is  at  a  loss  to  say  whether  such  removal 
is  complete. 

A  carcinomatous  scirrhus  is  to  be  distinguished  from  ordinary 
scirrhus  principally  by  the  peculiar  darting,  lancinating  pains 
which,  sooner  or  later,  always  appear  in  it;  these  pains  are 
markedly  diagnostic.  Again,  a  scirrhous  carcinoma  is  apt  to  have 
a  hereditary  history:  a  generation  may  have  escaped,  but  it  will  be 
discovered  somewhere  in  the  family.  In  this  respect,  my  experience 
leads  me  to  infer  that  it  is  really  a  more  persistent  type  of  carcinoma 
than  encephaloma.  Encephaloma  is  more  quickly  fatal,  Init  is  less 
persistent. 

All  local  medication  to  a  carcinomatous  scirrhus  is  worse  than  use- 
less.    If  it  is  not  widely  cut  away,  it  is  better,  a  hundred  times,  to 


576  ORAL  DISEASES  AND  SURG  ERF. 

do  nothing  at  all  to  it.  Many  a  tumor  of  this  class  that  would 
have  remained  dormant  for  years  has  been  excited  to  the  most  de- 
structive malignancy  by  overofficious  meddling  with  it.  If  a  prac- 
titioner does  not  know  the  character  of  a  tumefaction  upon  a  tongue, 
he  cannot  act  more  wisely  than  to  do  nothing  at  all,  until,  at  least, 
time  and  continued  observation  have  made  plain  to  him  the  diag- 
nosis. 

At  a  period  very  various  as  to  time,  a  scirrhous  carcinoma  ulcer- 
ates. If  the  tumor  has  attained  any  size,  fungous  granulations  sprout 
forth,  giving  that  expression  known  as  fungus  haematodes  ;  if,  on 
the  contrary,  the  tumor  ulcerates  while  small,  it  is  irregular,  puck- 
ered, everted  in  its  edges  or  elevated,  and  covered  with  abundant 
granulations:  the  discharge  maybe  thin  and  sanious,  or  purulent, 
the  latter  character  being,  however,  rare :  it  differs  from  the  syphi- 
litic sore  in  its  granulative  bottom. 

A  section  of  scirrhous  carcinoma  presents  a  stroma  dense,  abun- 
dant, and  closely  meshed.  A  fibrous  structure  is  always  more  or 
less  marked,  particularly  in  its  occult  state,  such  structure  assimi- 
lating both  the  white  and  yellow  tissues,  being  perhaps  really  these 
tissues.  A  diagnostic  sign  is  a  peculiar  creak  or  cry  given  under 
the  knife.  Another  is  ^  shrinkage  or  contraction  in  the  center  of  a 
section.  Still  another  is  a  creamy  juice,  which  may  often  be  scraped 
from  it. 

In   looking   at  a  microscopic  slice  of  scirrhous   carcinoma,   the 

Fig.  104. 


A  microscopic  view  of  the  cancer-cells  filling  the  interstices  among  the  bundles  of  the 
fibro-cellular  tissue  in  the  skin  of  the  breast.  Magnified  about  two  hundred  times. 
(After  Paget.) 

areolae  existing  in  the  stroma  are  found  filled  with  granules,  nuclei, 
and  nucleated  cells,  these  cells  being  of  most  diversified  form,  and 


THE   TONGVE  AND   ITS  DISEASES. 


01  i 


common  to  no  tissue:  the  term  heteroclitic  is  justly  applied  to  them 
The  appearance  of  such  a  section  is  exhibited  in  the  eno-ravin-r" 
Fig.  104.  '' 

"  It  is  well  known  that  whenever  a  special  predisposition  to  al)- 
normal  action  exists  in  the  vital  economy,  a  very  slight  thing  is  suf- 
ficient to  act  as  an  exciting  cause  of  disease.  This  is  especially  the 
case  in  many  affections  of  both  an  organic  and  dynamic  character, 
examples  of  which  we  have  occasionally  presented,  among  which 
was  the  apparent  development  of  cancer  from  the  irritation  pro- 
duced by  rough  or  decayed  teeth.  Additional  evidence  upon  this 
point  is  furnished  by  the  following  cases  from  the  clinical  report  on 
epithelial  cancer,  by  Mr.  Jonathan  Hutchinson,  in  the  Medical  Times 
and  Gazette :  '  George  P.,  aged  thirty-six,  a  dark,  sallow,  but  health}-- 
looking  man,  was  admitted,  December  29,  1853,  into  St.  Bartholo- 
mew's Hospital,  under  the  care  of  Mr.  Stanley,  for  a  cancerous  ulcer 
in  the  middle  of  the  right  margin  of  the  tongue,  ahout  an  inch  in 
length,  half  an  inch  in  width,  and  half  a  line  to  a  line  in  depth.  The 
base  was  irregular,  not  granular,  nor  distinctly  nodular  or  warty;  it 
was  clean  and  moderately  florid,  and  while  in  the  hospital,  and  being 
guarded  from  the  teeth  by  an  ivory  cover  for  them,  it  became  level, 
and  skinned  over  very  thinly,  yet  enough  to  prevent  its  bleeding 
when  lightly  rubbed.  The  borders  of  the  ulcer  were  upraised,  with 
a  somewhat  lobed  or  glandular  surface.  This  was  especially  the 
case  with  the  upper  border,  which,  occupying  a  portion  of  the  dorsum 
of  the  tongue,  overhung  a  little  the  adjacent  mucous  membrane. 
The  elevated  border  felt  firm,  tense,  and  nearly  hard  ;  the  base  of 
the  ulcer  was  equally  so,  and  these  characters  were  evidently  de- 
rived from  morbid  deposits  at  and  for  about  two  to  three  lines  beyond 
the  ulcerated  surface.  At  the  border  this  deposit  did  not  involve  the 
very  surface  layer  of  the  mucous  membrane,  which  was  tensely 
stretched  over  it,  but  discernible  with  its  small  vessels.  The  rest 
of  the  tongue  appeared  to  be  all  healthy.  One  lymph-gland  by  the 
side  of  the  facial  artery  was  slightly  enlarged,  firm,  but  not  hard. 
The  teeth  by  the  side  of  the  ulcer  were  not  rough,  but  neither  were 
they  clean,  and,  as  already  said,  the  ulcer  became  smoother  and 
skinned  over  when  protected  from  them. 

'"He  said  that  nine  months  jireviously  his  tongue  had  become 
sore  through  the  "  fretting"  of  a  decayed  tooth  at  this  part.  He 
allowed  the  tooth  to  remain  for  six  months,  the  sore  extending  all 
the  time  until  it  had  reached  its  present  dimensions.  At  length, 
three  months  ago,  the  tooth  was  drawn ;  the  sore  remained,  and  he 

37 


578  ORAL  DISEASES  AND  SURGERY. 

was  not  aware  of  any  change  in  its  character.  It  was  always  very 
painful,  and  the  pain  extended  from  it  over  the  whole  cheek  and  the 
side  of  the  head  and  jaw.  Many  of  the  cervical  lymphatic  glands 
under  the  right  side  of  the  jaw  had  been  enlarged,  but  they  had 
subsided  two  months  previously ;  and  the  one  by  the  facial  artery 
had  only  in  the  last  week  been  enlarged.  His  great-aunt  died  of 
cancer  of  the  throat  (sufficiently  proved) ;  but  no  other  relative  was 
known  to  have  had  cancer.  He  never  had  any  syphilis  or  well- 
marked  struma.' 

"After  an  ineffectual  effort  to  remove  the  disease  by  constitutional 
treatment  with  iodide  of  potassium,  the  part  was  excised,  the  trou- 
blesome symptoms  subsided,  the  patient  recovered,  and  is  still  in 
good  health, — eleven  years  after  the  operation. 

"  '  Caroline  C,  aged  thirty-five,  a  married  woman,  and  the  mother 
of  three  children,  was  admitted,  February,  1855,  into  Middlesex 
Hospital,  under  the  care  of  Mr.  De  Morgan.  She  was  subject  to 
dyspepsia;  but  during  the  last  few  years  she  had  been  in  rather 
better  health.  She  had  broken  teeth  on  the  right  side  of  her  mouth, 
which  had  irritated  the  tongue.  Tw^o  years  before  her  admission 
she  noticed  that  her  tongue  was  sore,  and  a  year  ago  a  lump  began 
to  form  in  it.  Mr.  De  Morgan  removed  the  right  side  and  tip  of  the 
tongue  by  ligature.  He  made  an  incision  in  the  median  line  beneath 
the  jaw,  and  dissected  his  way  upward,  and  then,  having  passed  the 
ligature,  tied  it  over  a  wooden  bridge,  which  was  fixed  as  a  sort  of 
tourniquet.  In  ten  days  or  a  fortnight  it  had  separated.  On  March 
19th  both  the  wound  below  the  jaw  and  that  of  the  tongue  were 
quite  healed.  There  was  then,  however,  suspicious  hardening  about 
the  cicatrix.  The  disease  soon  afterward  returned  in  the  stump, 
and  in  the  course  of  a  few  months  the  woman  died.' 

"'Daniel  H.,  aged  forty-six,  was  admitted,  November  2d,  1860, 
into  St.  Thomas's  Hospital,  under  the  care  of  Mr.  McMurdo.  He 
stated  that  twelve  months  ago  he  experienced  a  soreness  of  his 
tongue  on  the  left  side,  which  he  imagined  W'as  due  to  irritation  of 
some  decayed  teeth.  Several  had  been  removed  in  consequence,  but 
nothing  was  done  for  the  tongue.  The  ulcer  in  the  latter  grew  more 
painful,  and  five  months  ago  the  glands  below  the  jaw  began  to  en- 
large. There  is  at  present  an  ulcer  on  the  left  and  under  side  of  the 
tongue.  This  half  of  the  tongue  is  hardened,  swollen,  and  very 
painful ;  and  he  speaks  with  great  difficulty,  from  pain  in  moving 
the  tongue,  which  is  also  not  able  to  be  much  moved,  from  being 
swollen,  and  tied  down  bv  the  ulceration  and  induration.     He  suf- 


THE   TONGUE  AND   ITS  DISEASES.  579 

fers  a  great  deal  of  pain.  His  health  has  generally  been  good,  and 
he  says  that,  except  for  the  local  distress,  he  feels  well.  He  is,  how- 
ever, very  sallow,  haggard,  and  emaciated.' " 

Purely  benign  localized  tumors  of  the  sarcomatous  class,  as  the 
fibrous,  the  fibro-plastic,  and  the  cartilaginous,  are  those  with  which 
scirrhous  carcinoma  is  most  apt  to  be  confounded. 

As  scirrhous  carcinoma  always  begins  upon  the  sides  of  the 
tongue,  jagged  and  sharp  teeth  irritating  the  parts  may  l)e  su[)posed 
to  have  some  influence  in  its  localization ;  such  teeth,  under  all  cir- 
cumstances, should  be  removed  or  smoothly  dressed.  I  have  seen 
many  an  epithelial  carcinoma  so  located. 

In  the  treatment  of  scirrhus  of  the  tongue  by  amputation,  several 
modes  have  been  employed.  One,  that  of  the  French  school,  is  by 
means  of  an  instrument  known  as  the  ecraseur  of  Chassaignac. 
This  is  simply  a  delicate  chain  arranged  from  a  handle,  which  little 
by  little  crushes  off  the  part.  Another  mode,  that  of  strangula- 
tion, consists  in  the  introduction  of  circumscribing  ligatures,  which, 
being  drawn  tightly,  cut  off  all  circulation  from  the  diseased  part, 
thus  compelling  its  separation.  Still  another  is  the  use  of  caustic 
remedies  ;  of  these  there  is  a  great  variety, — arsenic,  however, 
forming  the  base  of  most  of  them.  No  remedies  require  to  be  used 
with  more  judgment  and  caution.  If  the  practitioner  desires  to  try 
a  caustic,  my  own  experience  would  suggest  chloride  of  zinc  : 

R. — Zinci  chl. 

Alum  pulv.  aa  gr.  v; 
Acid,  tannic,  gr.  ij ; 
Ferri  persulph.  gr.  iij ; 
Glycerin  q.  s.  for  a  paste.     M. 

To  apply  this  paste,  draw  the  tongue  forward,  hold  it,  and  dry  it 
carefully  in  a  napkin.  Lay  some  crystals  of  zinc  on  the  part  and 
cover  over  with  the  paste.  This  may  be  allowed  to  remain  as  long 
as  the  tongue  can  be  kept  dry.  Finally,  wash  the  debris  away,  an.l 
the  application  is  completed. 

It  may  happen,  after  such  an  application,  that  severe  general  glos- 
sitis will  supervene;  this  will  be  unfortunate,  and  will  imply  that 
much  more  harm  than  good  has  been  done.  In  making  a  caustic 
impression  under  such  circumstances,  the  parts  should  be  quickly 
killed,  not  excited  and  provoked. 

The  knife,  the  best  instrument,  removes,  as  is  seen  in  the  plate, 
all  the  parts  supposed  to  be  involved.     Whether  such  knife  be  in  the 


580  ORAL   DISEASES  AND  SURGERY. 

form  of  the  scalpel  or  scissors,  it  is,  I  think,  the  best  instrument  at 
our  command,  at  least  in  the  present  state  of  our  knowledge  of  such 
disease. 

Injection  of  persulphate  of  iron  is  a  means  much  employed  and 
commended.  My  own  experience  with  it,  however,  has  not  led  me 
to  look  upon  it  as  a  specific. 

The  arrows  of  Maisonneuve,  tipped  with  zinc,  may  be  used  by  those 
who  do  not  fear  a  resulting  inflammation.  Two,  thi'ee,  or  more  of 
such  arrows  may  be  made  to  circumscribe  the  tumor,  precisely  as 
practiced  by  this  surgeon  in  his  operations  upon  the  mammary 
gland. 

Benign  Scirrhus. — Scirrhus  of  the  tongue,  purely  fibrous  or  car- 
tilaginous in  character,  is  frequently  met  with.  Such  tumors  appear 
in  the  form  of  lobules,  or  isolated  masses.  They  are  painless,  with 
the  exception  of  a  soreness,  the  result  of  their  interference  with 
function  ;  they  do  not  tend  to  ulcerate,  and  when  removed  by  the 
knife,  do  not  return.  Section  of  them  by  the  knife,  and  examina- 
tion under  the  microscope,  show  their  relationship  with  normal  tis- 
sues, and  thus  dissipate  apprehension.  These  tumors,  however, 
belonging  to  the  sarcomatous  class,  may  degenerate. 

Encysted  Tumors. — Cystic  tumors  of  the  tongue  are  not  unfre- 
quent.  That  known  as  meliceris  is  round,  free  from  pain,  and  filled 
with  a  glutinous,  honey-like  substance.  A  peculiarity  of  this  cyst 
is  found  in  the  fungiform  character  of  its  bottom,  this  portion  look- 
ing pyogenic.  A  second  order  of  cysts  contains  lymph,  sometimes 
colloid  in  consistence  and  appearance,  at  others  flaky,  or,  it  may  be, 
puriform. 

Says  Sir  Benjamin  Brodie.  "There  is  a  disease  of  the  tongue 
which  I  have  seen  every  now  and  then,  and  which  I  am  sure  is  very 
often  mistaken  for  cancer,  though  it  is  of  a  different  nature.  It  is  a 
curable  disease,  although  it  looks  like  a  malignant  one  in  many  re- 
spects. The  first  thing  of  which  the  patient  complains  is  enlarge- 
ment of  the  tongue,  with  some  pain.  On  examination,  you  find  a 
tumor  in  one  pa^rt  of  it,  not  very  well  defined,  nor  with  any  distinct 
margin.  It  is  a  softish  tumor,  and  increases  in  size,  and  perhaps 
another  tumor  appears  in  a  different  part  of  the  tongue,  and  that  in- 
creases also.  There  may  be  three  or  four  of  these  soft  elastic  tumors, 
with  no  very  defined  margins,  in  various  parts  of  the  tongue.  This 
is  the  first  stage  of  the  disease. 

"  In  the  second  stage  there  is  a  small  formation  of  matter  in  one 
of  these  tumors, — a  little  abscess,  which  breaks  externally,  discharg- 


THE   TONGUE  AND   ITS  DISEASES.  5S1 

ing  two  or  three  drops  of  pus.  When  the  abscess  has  burst  it  does 
not  heal,  but  another  forms  in  one  of  the  other  tumors.  These  al)- 
scesses  may  assume  the  form  of  ulcers,  and  the  ulcers  have  a  par- 
ticular appearance.  In  the  first  instance  it  is  a  very  narrow  streak 
of  ulceration,  but  on  introducing  a  probe  you  find  that  the  ulcer  is 
the  external  orifice  to  a  sort  of  fissure-  in  the  tongue.  The  probe 
passes  in  obliquely ;  the  tongue  is,  as  it  were,  undermined  by  the 
ulcer,  a  flap  of  the  substance  of  the  tongue  being  over  it. 

"  The  disease  now  becomes  more  painful,  and  at  last  the  ulcers 
may  spread  externally.  In  some  instances  they  occupy  a  very  con- 
siderable portion  of  the  surface  of  the  tongue,  but  generally  they 
burrow  internally,  and  do  not  spread  much  toward  the  surface. 
This  is  a  very  distressing  state  of  things,  and  a  man  may  remain 
in  this  state  for  a  long  time.  The  glands  of  the  neck  do  not  Ijo- 
come  affected,  nor  does  the  general  health  suffer,  except  from  the 
difficulty  of  swallowing  food.  This  is  one  inconvenience  experienced 
by  the  patient ;  and  he  also  labors  under  a  difficulty  of  articulation. 
The  tongue,  from  its  enlarged  state,  may  become  stiff,  not  sufficiently 
pliable  for  the  purposes  of  speech,  and  the  patient  either  speaks  thick 
or  lisps. 

"  In  some  instances  the  disease  may  be  relieved  by  a  course  of 
sarsaparilla,  with  small  doses  of  bichloride  of  mercury.  A  strong 
decoction  of  sarsaparilla,  with  from  a  quarter  to  half  a  grain  of  bi- 
chloride of  mercury,  may  be  taken  in  the  course  of  the  day.  Of 
course,  if  there  be  anything  wrong  in  the  general  health,  you  should 
endeavor  to  get  that  corrected,  and  attend  especially  to  the  state  of 
the  bo^vels  and  the  secretion  of  the  liver.  If  the  secretions  of  the 
digestive  organs  be  unhealthy,  a  dose  of  senna  and  salts  may  be 
given  every  other  morning,  and  blue  pill  every  other  night.  When 
the  patient  is  brought  into  this  state,  one  remedy,  as  I  have  said,  is 
sarsaparilla  with  bichloride  of  mercury ;  but,  according  to  my  experi- 
ence, this  is  not  the  best  remedy.  The  remedy  best  adapted  for 
these  cases  is  a  solution  of  arsenic.  Give  the  patient  five  minims 
three  times  daily,  in  a  draught,  gradually  increasing  the  dose  to  ten 
minims.  It  should  be  taken  in  full  doses,  so  that  it  may  begin  to 
produce  some  of  its  poisonous  effects  on  the  system.  When  it  be- 
gins to  act  as  a  poison,  it  will  show  itself  in  various  ways.  Some- 
times there  is  a  sense  of  heat,  a  burning  pain  in  the  rectum  ;  some- 
times griping,  purging,  and  sickness,  and  nervous  tremblings.  A 
patient  who  is  taking  arsenic,  especially  in  pretty  large  doses,  ought 
to  be  carefully  watched.     At  first  you  may  see  him  every  two  or 


582  ORAL  DISEASES  AND   SURGERY. 

three  days,  and  then  every  day  ;  and  as  soon  as  the  arsenic  begins 
to  operate  as  a  poison,  leave  it  off.  "When  this  effect  is  produced, 
the  disease  of  the  tongue  generally  gets  well ;  but  at  any  rate  leave 
off  the  arsenic,  and  the  poisoning  will  not  go  too  far;  it  will  do  no 
harm.  If,  after  a  time,  you  find  that  the  disease  is  relieved,  but  not 
entirely  cured,  you  may  try  another  course  of  arsenic.  Perhaps  it 
may  take  a  considerable  time  to  get  the  tongue  quite  well.  Sarsa- 
parilla,  with  the  bichloride  of  mercury,  may  be  given  at  one  time  ; 
and  at  another,  arsenic.  You  cannot  give  either  of  these  remedies 
forever,  and  indeed  the  arsenic  can  only  be  given  for  a  very  limited 
period  ;  but  it  is  astonishing  what  bad  tongues  of  this  description  I 
have  seen  get  well  under  these  modes  of  treatment,  especially  under 
the  use  of  arsenic." 

A  form  of  cystic  tumor,  being  a  cystiform  hypertrophy  of  a  cir- 
cumvallate  papilla,  is  met  with  occasionally  on  the  back  part  of  the 
dorsum.  These  tumors  have  attained  the  size  of  a  walnut.  To  the 
touch  they  are  very  solid,  the  walls  being  veiy  much  indurated.  If 
convinced  that  there  is  no  malignant  association,  the  practitioner 
may  puncture  the  sac  and  introduce  a  tent.  Iodine  may  be  used 
both  externally  and  by  injection. 

Acute  Glossitis. — Acute  inflammation  of  the  tongue,  whether  of 
idiopathic  or  of  traumatic  character,  is  always  to  be  looked  on  with 
concern.     The  causes  inducing  this  condition  are  various. 

Viewed  as  a  distinct  condition,  and  this  view,  no  matter  Avhat 
the  cause,  will  always  force  itself  on  the  attention  of  the  practitioner 
when  called  to  a  case,  the  most  urgent  necessity  will  nearly  always 
be  felt  for  a  treatment  that  shall  abort  or  resolve  the  phenomena  as 
quickly  as  possible.  It  is  true  that  all  glossal  inflammations  are 
not  dangerous ;  but  all  inspire  Avith  a  sense  of  danger. 

Acute  glossitis,  idiopathic  in  form,  commonly  begins  with  a  sense 
of  enlargement  and  stiffness  of  some  part  of  the  organ,  generally  the 
anterior  part ;  this  soon  becomes  red,  painful,  and  perceptibly 
swollen.  At  this  stage  the  condition  may  rest,  and  after  some 
little  time  commence  to  decline.  On  the  other  hand,  a  single  hour 
may  witness  the  extension  of  the  inflammation  to  an  extent  which 
shall  threaten  or  perhaps  produce  suffocation.  In  still  other  in- 
stances the  advance  is  gradual ;  the  circulation  sympathizing,  the 
pulse  grows  rapid  and  irritable,  the  skin  becomes  hot,  only  to  de- 
cline to  the  cold  sweating  stage ;  and  suppuration  or  perhaps  gan- 
grene terminates  the  action. 

The  dangerous  character  of  glossitis  demands  the  most  energetic 


THE   TONGUE  AND    ITS  DISEASES.  583 

treatment.  Leeches  direct  to  the  organ  or  beneath  the  jaw,  bleeding 
from  the  arm,  catharsis,  diaphoresis,— any  or  all  of  these  means  are 
successively  to  be  brought  into  requisition.  A  plan  of  treatment, 
reliable  as  any  in  character,  may  thus  be  pursued:  place  on  the 
back  of  the  neck  a  cataplasm  of  mustard  and  red  pepper;  put  the 
feet  in  water  as  hot  as  can  be  endured  y  give  a  full  dose  of  sulphate 
of  magnesia.  If  now  the  disease  does  not  seem  to  be  immediately 
held  in  check,  put  the  patient  in  bed  and  administer  spirits  of  Min- 
dererus  until  full  diaphoresis  is  secured.  If  even  yet  control  is  not 
secured,  let  fifty,  seventy,  or  a  hundred  American  leeches,  or  a 
third  of  the  quantity  of  Swedish,  be  placed  beneath  the  jaw.  If 
the  action  is  still  unconquered,  blood  pro  re  nata  is  to  be  taken  from 
the  arm,  and  the  tongue  itself  is  to  be  freely  incised.  If  yet  the 
swelling  goes  on,  and  suffocation  be  threatened,  laryngotomy  or 
tracheotomy  is  made  a  necessity.  (See  these  operations.) 

A  case  presented  before  the  North  London  Medical  Society  will 
be  found  interesting  and  suggestive  in  this  connection : 

"  Mr.  J.  Z.  Laurence  exhibited  the  tongue  of  a  woman  who  had 
died  of  acute  inflammation  of  the  organ.  She  had  been  under  Mr. 
Laurence's  care  for  acute  rheumatism,  when,  on  the  evening  of  the 
5th  November,  he  was  called  to  her,  and  found  her  sitting  up  in  the 
bed,  with  a  countenance  expressive  of  the  greatest  anxiety,  her  face 
pale  and  bedewed  with  sweat;  she  breathed  at  long  intervals,  and 
laboriously;  pulse  130.  The  cause  of  this  was  evident;  she  could 
not  open  her  mouth  to  speak,  for  a  swelling  of  the  left  half  of  the 
tongue,  which  was  red,  dry,  and  glassy.  On  the  night  of  the  2d 
and  3d  she  had  had  severe  rigors.  Mr.  Laurence  at  once  made  three 
free  incisions  into  the  tongue,  and  about  half  a  pint  of  blood  escaped. 
About  two  hours  after  the  bleeding  had  ceased,  the  submaxillary 
region  began  to  swell,  twelve  leeches  were  applied,  and  on  the  follow- 
ing morning  the  right  half  of  the  tongue  began  to  swell,  and  by  the 
afternoon  it  had  attained  full  as  great  a  size  as  the  left.  With  this 
was  a  corresponding  engorgement  of  the  tissues  about  the  jaw ;  the 
local  depletion  had  had  very  little  effect  in  reducing  the  swelling  of 
the  left  side  of  the  tongue  ;  generally  she  was  worse ;  rigors  now 
came  on,  and  the  pulse  intermitted  three  or  four  beats.  Mr.  Quain 
saw  her,  and  proposed  incising  the  right  half  of  the  tongue,  but 
both  patient  and  friends  objected.  Mr.  Laurence  saw  her  the  la^t 
time  alive  the  same  night;  her  surface  was  deadly  cold;  pulse  not 
perceptible  at  the  wrist,  yet,  strangely  enough,  the  respiration  went 
on  tranquilly,  though  feebly.     Mr.  Laurence  at  once  perceive.l  that 


584  ORAL  DISEASES  AND  SURGERY. 

she  was  dying  of  slow  asphyxia,  and  that  her  only  chaace  was  in 
tracheotomy;  this  was  proposed  with  more  impressive  force  than 
a  surgeon  almost  dare  do.  She  and  her  husband  doggedly  refused  ; 
next  morning  she  was  dead. 

"Autopsy. — Xo  organic  disease  was  discoverable.  The  whole  of 
the  tongue  was  swollen,  pale,  and  soft  from  maceration  in  a  puro- 
serous  fluid,  which  infiltrated  the  substance.  The  superior  aperture 
of  the  larynx  was  greatly  narrowed  by  serous  effusion ;  the  rima 
glottidis  to  a  less  extent;  below  this  point,  the  whole  of  the  trachea 
was  perfectly  unobstructed ;  the  submaxillary  region  and  anterior 
triangles  of  the  neck  were  infiltrated  Avith  a  serous  fluid,  which, 
among  the  suprahyoid  muscles,  had  assumed  a  purulent  aspect. 
The  lungs  were  singularly  healthy ;  the  heart,  kidneys,  and  bladder 
presented  no  signs  of  disease. 

"  From  the  above  facts,  it  follows  that  tracheotomy  would  in  all 
probability  have  saved  the  woman's  life ;  and  Mr.  Laurence  believes 
he  proposed  it  at  the  proper  time.  It  is  true  there  was,  throughout 
the  case,  not  one  fit  of  suffocation.  On  the  contrary,  she  died  choked 
in  the  most  gradual  conceivable  manner ;  and  were  he  to  meet  with 
another  case,  he  would  not  defer  the  operation  until  the  patient  was 
in  his  last  gasp,  as  was  too  commonly  the  case,  but  resort  to  it  as 
soon  as  he  saw  the  patient  sinking,  previous  measures  not  having 
ameliorated  his  condition.  A  curious  pathological  fact,  which  Mr. 
Laurence  noticed  and  pointed  out  to  Mr.  Phillips,  who  attended  the 
case  with  him,  was  the  successive  and  separate  invasion  of  the  two 
halves  of  the  tongue  by  the  inflammatory  action,  offering  a  remark- 
able instance  of  the  dependence  of  pathological  changes  on  the  ana- 
tomical distribution  of  the  blood-vessels." 

Abscess. — In  depraved  and  tainted  conditions  of  the  system,  ab- 
scesses, of  what  might  be  called  a  cold  character,  occasionally  form 
among  the  deeper  muscles  of  the  tongue ;  such  abscesses  arc  not 
necessarily  associated  with  any  marked  inflammator}'"  phenomena, 
but  may  have  attention  first  directed  toward  them  by  the  swelling 
which  appears  on  the  under  surface. 

The  proper  treatment  in  these  cases  will  be  found  in  voiding  the 
matter  through  puncture  as  soon  as  fluctuation  is  perceived ;  other- 
wise it  has  happened  that  the  pus  has  dissected  its  way  down  the 
neck,  pointing  in  front  of  the  hjo\&  bone,  creating  much  derange- 
ment, and  threatening  even  a  fatal  result.  Treat  these  cases  by 
local  stimulating  injections  and  the  internal  administration  of  tonic 
medicines. 


THE   TONGUE  AND   ITS  DISEASES. 


585 


The  following  suggestive  case  of  abscess  of  the  tono-ue  enclino- 
fatally  from  hemorrhage,  is  related  by  Mr.  Ward,  being  presented 
before  the  London  Medical  Societv : 

"E.  T ,  aged  seven,  was  born  with  a  slight  red  enlargement 

in  the  center  of  the  tongue.  No  inconvenience  or  difficulty  in  the 
ordinary  motions  of  the  tongue,  or  in  swallowing,  had  ever  been  ex- 
perienced ;  the  general  health  had  always  been  good.  In  the  night 
of  Sept.  2Uh,  184T,  having  been  in  her  usual  health  at  bedtime,  she 
was  attacked  with  pain  and  swelling  under  the  chin  and  both  sides 
of  the  lower  jaw ;  slept  very  little,  and  the  following  morning  had 
pain  in  the  tongue,  with  great  difficulty  in  speaking,  or  swallowing 
anything  but  liquids.  She  had  an  aperient  powder  at  night,  and  the 
lower  jaw  was  fomented  frequently.  In  this  state  she  continued  for 
two  or  three  days,  and  was  visited  by  me  on  Oct.  1st,  when  the  fol- 
lowing appearances  were  noted :— Face  flushed ;  eyes  very  bright ; 
countenance  anxious  ;  great  swelling,  redness,  and  extreme  tender- 
ness of  the  parts  under  the  lower  jaw ;  very  slight  swelling  of  the 
tongue  itself,  which  is  covered  with  a  thick,  brown  fur ;  is  unable  to 
open  the  mouth  wide,  or  move  the  tongue  beyond  the  teeth,  or 
to  speak,  and  has  great  pain  in  the  mouth  ;  pulse  very  quick  and 
sharp ;  great  heat  of  skin,  and  thirst  urgent ;  bowels  confined. 
Ordered  eight  leeches  to  be  applied  under  the  chin  ;  to  take,  at  bed- 
time, four  grains  of  calomel ;  James's  powder  and  sugar,  of  each 
three  grains;  a  saline  mixture,  containing  a  scruple  of  nitrate  of 
potash  ;  one  tablespoonful  every  three  or  four  hours. 

"  Oct.  2d.  Slept  more  last  night  than  since  first  attacked ;  fever 
great;  pain  slightly  relieved;  swelling  and  redness  less;  mouth 
I  nearly  closed ;  was  able  to  swallow  the  powder  in  jelly,  but  refuses 
the  mixture,  of  which  very  little  has  been  taken ;  bowels  freely  re- 
lieved, evacuations  dark  and  offensive  ;  to  take  calomel  and  James's 
powder,  of  each  three  grains,  and  jalap,  five  grains,  at  bedtime ; 
use  a  chloride-of-soda  gai'gle,  warm,  to  the  mouth,  by  means  of  a 
syringe.     Fluids  taken  in  the  mouth  I'eturu  by  the  nose. 

"4th.  Less  fever;  rests  better  at  night;  difficulty  in  swallowing 
or  speaking  the  same;  can  open  the  mouth  sufficiently  to  allow  the 
tongue  to  be  seen,  which  is  nearly  fixed,  very  little  swollen,  and  still 
1  thickly  coated;  the  breath  extremely  fetid;  external  redness  and 
■swelling  still  considerable;  the  tenderness  great ;  pulse  soft,  quick, 
and  weak;  the  bowels  act  freely;  was  able  to  pass  my  finger  into 
the  mouth  ;  under  each  side  of  the  tongue  distinct  fluctuation  can  be 
•felt ;  while  pressing  on  the  left  side  the  lining  membrane  gave  way, 


586  ORAL  DISEASES  AND  SURGERY. 

and  was  followed  by  a  profuse  discharge  of  fetid  pus,  mixed  with 
blood ;  the  point  of  the  finger  passed  easily  to  the  depth  of  the  first 
joint,  under  the  tongue,  giving  the  sensation  of  a  large  pulp  cavity; 
the  tongue  not  very  tender,  can  be  moved  from  side  to  side  by  means 
of  a  small  teaspoon,  but  not  voluntarily.  Apply  strong  poppy  fo- 
mentation frequently,  and  linseed  poultice ;  continue  the  chloride-of- 
soda  gargle  under  the  tongue,  with  the  syringe,  and  take,  of  a  mix- 
ture consisting  of  six  grains  of  quinine,  a  teaspoonful  every  four 
hours;  give  a  little  port  wine  and  water  frequently,  and  milk  or  thin 
arrowroot  for  drink. 

."  6th.  The  pain  less  since  the  use  of  the  poppy  fomentation,  gen- 
erally sleeping  for  some  hours  after  using  it;  the  discharge  of  pus 
and  saliva  very  copious  and  offensive ;  lies  with  the  head  on  the  left 
side  to  allow  the  free  exit  of  the  discharge,  otherwise  the  mouth  is 
constantly  filled ;  fever  less,  as  also  the  swelling  and  tenderness ; 
redness  gone ;  great  debility  and  considerable  wasting  of  the  body 
already ;  can  swallow  fluid,  and  is  eager  for  the  wine ;  very  little 
quinine  has  been  taken  ;  bowels  act  twice  a  day ;  can  open  the  mouth 
wider,  but  is  still  unable  to  protrude  the  tongue,  which  is  cleaner 
and  moister;  on  slightly  raising  it  by  the  handle  of  a  spoon,  a  large 
jagged  opening  may  be  seen  on  the  left  under  side  of  the  lower  jaw, 
from  which,  by  gentle  pressure  under  the  chin,  a  profuse  discharge 
of  thick  pus  wells  up,  of  which  I  pressed  out  at  least  two  ounces  ; 
pulse  soft  and  weak.  Continue  the  external  applications  ;  apply  the 
chloride-of-soda  gargle  frequently  to  the  mouth  and  under  the 
tongue,  with  the  syringe ;  take  a  mixture  consisting  of  two  ounces 
and  a  half  of  decoction  of  bark,  syrup  of  orange-peel,  and  tincture 
of  bark,  of  each  two  drachms,  a  fourth  part  three  times  a  day  ;  con- 
tinue the  wine,  and  give  strong  beef-tea  and  arrowroot  frequently. 

"9th.  Altogether  improved;  discharge  less,  but  still  fetid;  takes 
fluid  nourishment  frequently,  and  the  wine;  the  general  swelling  and 
the  tenderness  reduced ;  more  on  the  left  side  under  the  jaw  than 
the  right,  and  is  unable  to  protrude  the  tongue  further.  Continue 
all  the  applications  and  the  mixture. 

"  11th.  Has  not  rested  so  well  the  last  two  nights,  and  has  had 
more  pain,  particularly  on  the  right  side,  which  is  more  swollen 
and  very  tender,  the  left  side  being  almost  in  its  natural  state  ;  the 
discharge  has  been  profuse,  but  thinner ;  the  tongue  is  moist  and 
clean;  not  very  tender,  but  less  movable;  the  opening  under  the 
left  side  of  the  tongue  smaller  ;  fever  returned ;  has  constant  hack- 
ing cough ;  not  able  to  swallow  so  well,  or  to  speak  so  as  to  be 


THE    TONGUE  AND  ITS  DISEASES. 


587 


understood.  Apply  six  leeches  under  right  side  of  loAver  jaw; 
continue  the  fomentations  and  poultices;  also,  bark  mixture  and 
port  wine. 

"  12th.  Has  slept  very  little  from  the  frequent  coughing,  which 
tires  her  very  much;  discharge  from  the  mouth  less  and  thinner, 
but  still  fetid;  emaciation  extreme;  has  changed  the  position  of 
lying  to  the  right  side ;  left  angle  of  the  mouth  drawn  down ;  the 
swelling  and  tenderness  on  the  right  side  very  much  increased  since 
yesterday;  feels  soft;  is  more  prominent  in  the  center,  and  appears 
pointing  here  ;  the  finger  in  the  mouth  can  detect  very  distinct 
fluctuation  under  the  tongue,  which  is  thickly  coated  and  very 
tender ;  takes  very  little  nourishment,  only  a  tea.?poonful  at  a  time : 
prefers  wine  to  other  things.  Continue  the  fomentations  and 
poultices. 

"  13th.  Has  had  a  bad  night ;  is  very  irritable  and  feverish ; 
mouth  nearly  closed ;  unable  to  examine  the  tongue ;  the  swelling 
about  the  same ;  the  right  cheek  and  under  side  of  the  jaw  of  a 
dusky  red  color,  and  very  shining;  so  tender  that  she  has  again 
changed  the  position  ;  lying  on  the  left  side ;  cough  less,  pulse  very 
small  and  weak ;  takes  scarcely  anything ;  discharge  more  copious, 
thicker,  and  slightly  tinged  with  blood ;  it  now  appears  to  come 
from  the  right  side.  In  the  evening,  while  coughing,  a  large  gush 
of  blood  took  place  from  the  mouth,  mixed  with  pus,  and  flowed 
freely  for  more  than  ten  minutes.  By  applying  ice  internally  and 
externally  (which  I  had  directed  to  be  in  readiness),  the  hemorrhage 
was  arrested.  A  cold  lotion  was  applied  externally,  and  an  alum 
gargle  frequently  to  the  mouth. 

"  14th.  Has  slept  very  little;  unable  to  lie  down,  from  the  con- 
stant discharge  of  fetid  pus  and  saliva  from  the  mouth  ;  the  swelling 
of  the  right  cheek  and  side  of  the  jaw  less ;  very  tender,  of  a  dull, 
yellowish  color;  able  to  open  the  mouth  so  as  to  examine  the 
tongue,  which  does  not  appear  enlarged ;  no  power  of  moving  it 
herself;  is  thickly  coated  with  a  dark  fur,  and  when  pressed  upon, 
a  profuse  discharge  of  thick  pus  fills  the  mouth  immediately ;  no 
return  of  the  hemorrhage;  is  very  pale  and  faint;  pulse  very  small 
and  weak;  has  taken  more  nourishment  since  last  night  than 
for  some  days  before,  such  as  port  wine,  isinglass  in  milk,  beef-tea, 
jelly,  etc.  Continue  the  lotion  and  alum-gargle  to  the  mouth  with 
a  syringe.  At  half-past  seven  p.m.,  in  the  act  of  swallowing  a  small 
piece  of  bread  and  butter,  profuse  hemorrhage  occurred  from  the 
mouth,  and  more  than  a  pint  of  blood  was  lost  before  it  was  again 


588  ORAL   DISEASES  AND  SURGERY. 

arrested  by  the  free  application  of  ice ;  it  was  of  a  bright  arterial 
color.     She  became  faint,  and  expired  at  nine  p.m. 

"  On  the  day  following  I  made  a  post-mortem  examination  of  the 
parts  affected.  The  parotid,  submaxillary  glands,  and  other  parts, 
having  been  brought  into  view,  were  found  (on  the  right  side)  so 
much  softened,  decomposed,  and  mixed  with  coagulated  blood  and 
pus,  as  to  be  recognized  with  diflBculty,  and  it  was  impossible  to 
trace  from  what  vessel  the  hemorrhage  proceeded,  such  was  the 
destruction  of  the  parts.  On  the  left  side,  the  glands  were  of  a 
greenish  color,  very  much  softened,  and  bathed  in  pus  A  probe 
passed  readily  by  the  side  of  the  jaw  into  the  mouth.  I  divided 
the  trachea  just  above  the  sternum,  and  dissected  the  larynx  and 
tongue  carefully  out.  The  morbid  state  of  the  tongue  is  shown  in 
the  preparation  before  the  society." 

In  the  discussion  which  ensued,  the  case  was  considered  a 
very  remarkable  one.  The  remarks  chiefly  had  I'eference  to  the 
cause  of  the  disease,  respecting  which  various  opinions  were  ex- 
pressed. 

Effusions. — The  tongue  is  occasionally  the  seat  of  most  formida- 
ble congestions  or  effusions.  In  the  space  of  a  single  hour  I  have 
known  an  inflamed  tongue  so  swell  as  almost  to  prevent  respira- 
tion. The  organ,  in  these  cases,  looks  so  vascular  that  one  hesitates 
to  use  the  knife,  when  enlargement  arrives  to  an  extent  which 
threatens  suffocation.  I  am  sure  I  suggest  the  very  best  practice 
when  I  say  incise  freely — cut  deeply  from  behind  forward,  either 
side  of  the  median  line,  avoiding,  however,  in  the  depth  of  the  cut, 
the  ranine  arteries.  The  wounds  thus  made  will  bleed  for  a  time 
freely,  indeed,  alarmingly ;  but  the  common  experience  is  that  they 
soon  close,  and  need  give  little  or  no  anxiety.  Yelpeau  has  recom- 
mended the  opening  of  the  ranine  veins  in  congestion.  Leeches  are 
also  applied  direct  to  the  tongue. 

Erysipelas. — A  formidable  danger  in  the  tongue  is  the  presence 
of  erysipelas:  this  may  be  idiopathic,  but  is  most  frequently  trau- 
matic, operations  about  the  jaws  being,  unfortunately,  liable  to  pro- 
voke this  condition.  The  treatment  of  erysipelas  in  the  tongue 
is  the  history  of  its  treatment  elsewhere.  Iron  and  quinia,  inter- 
nally and  locally,  should  be  freely  employed.  If  this  should  not  be 
found  effective,  then  make  incisions.  The  practitioner  is  never  to  for- 
get to  extend  his  observations  over  functional  disturbances  which 
may  exist. 

Bites  of  Insects. — The  most  severe  and  threatening  glossitis  I 


THE    TONGUE  AND   ITS  DISEASES. 


589 


ever  met  with  was  the  result  of  a  sting  of  a  wasp  taken  into  the 
mouth  while  eating  blackberries.  The  tongue  in  these  accidents 
swells  enormously,  yet,  happily,  tends  to  a  rapid  self-cure.  If  seen 
immediately,  the  very  best  application  is  dilute  ammonia ;  later,  we 
can  only  treat  such  an  inflammation  like  any  other  of  the  sthenic 
type.  It  is  well,  however,  to  remember  ^that  the  swelling  is  from 
effusion  rather  than  a  congestion  ;  incisions,  if  necessary,  may  always 
be  freely  made.  Iodine,  in  these  instances,  acts  sometimes  very  hap- 
pily ;  paint  the  tongue  thoroughly,  and  hold  cold  water  in  the 
mouth.  If,  unfortunately,  erysipelas  should  supervene,  the  iron 
and  quinia  combination  is  at  once  to  be  resorted  to.  In  these  cases 
the  pain  becomes  excessive,  the  parts  may  change  to  a  livid  hue, 
and  there  seems  to  be  a  decided  tendency  to  gangrene;  particu- 
larly is  this  the  case  in  depraved  and  broken-down  persons.  Free 
incisions  are  never  to  be  neglected:  the  erysipelas  in  these  cases 
depends  upon  the  separation  of  the  molecules — if  the  expression 
may  be  used — from  their  base  of  supply;  the  incisions,  draining  the 
organ,  allow  contraction  of  the  parts,  and  thus  restore  the  circu- 
latory relationship. 

In  ulcers,  or  in  tumefactions  of  the  tongue,  provoked  by  irritating 
teeth,  it  is  seldom  necessary  to  do  more  than  remove  the  source  of 
offense.  Cases  occur,  however,  where  some  after-treatment  is  de- 
manded, the  provoked  ulcer  being  indolent,  or,  in  some  instances, 
even  semi-gangrenous.  For  all  such  ulcers,  the  best  wash  that  I 
have  ever  used  is  water,  changed  in  color  to  a  milky  blue  by  the 
addition  of  the  compound  tincture  of  capsicum.  Where  a  part  is 
simply  indurated  and  not  ulcerated,  it  is  better,  for  a  time  at  least, 
to  leave  the  case  to  nature.  My  own  rule  is,  never  to  meddle  with 
an  induration  but  from  necessity.  In  all  these  cases  injudicious  med- 
dling will  be  found  very  bad  practice.  I  recall  an  instance  coming 
under  my  observation  a  short  time  since,  in  which,  while  in  the  act 
of  filling  a  tooth,  a  practitioner  had  thrust  an  instrument  quite  deeply 
into  the  tongue;  severe  inflammation  was  the  result,  the  eflfoct,  I 
imagine,  of  uncleanly  rust  or  blood-stain.  On  the  subsidence  of  the 
swelling,  the  wound,  being  found  to  discharge,  was  injected  with 
strong  solutions  of  nitrate  of  silver.  A  week  of  this  treatment  re- 
sulted in  the  formation  of  a  tubercle  as  large  as  a  hazel-nut ;  the 
injection  was  now  ordered  to  be  discontinued,  and  in  two  weeks  the 
tubercle  had  disappeared. 

Erectile  Tumors.— Of  the  erectile  growths  I  have  never  personally 
met  with  a  case  situated  upon  tbe  tongue ;  instances,  however,  are 


590  ORAL   DISEASES  AND  SURGERY. 

reported.  The  history  and  treatment  of  such  tumors  would  be  pre- 
cisely that  of  other  naevi. 

Fatty  Tumors. — These,  like  the  erectile,  are  uncommon.  A  case 
which  I  once  saw  exhibited  the  tumor  looking  like  a  mass  of  very 
smooth  fat,  encysted  by  the  mucous  membrane  :  the  situation  was  the 
inferior  left  surface  of  the  organ.  As  the  man  spoke,  the  tumor  would 
bulge  out  over  his  lower  teeth,  presenting  a  most  unsightly  appear- 
ance. The  patient  would  not  submit  to  an  operation,  and  it  was 
with  a  feeling  of  disappointment  that  I  afterward  found  myself  un- 
able to  follow  the  history  of  the  case. 

Metastatic  Disease. — The  example  herewith  given  explains,  with- 
out other  remarks,  a  character  of  trouble  rare,  yet  sometimes  met  with, 
upon  the  tongue.  We  may  recognize  in  the  disappearance  and  reap- 
pearance of  the  various  exanthems  an  explanation  of  the  condition. 
"  I  have  been  consulted,"  says  Mr.  Wm.  McClure,  in  a  paper  read 
before  the  Harveian  Society,  "  by  a  young  married  lady,  for  rather 
a  curious  affection.  She  informs  me  that  her  tongue  becomes  occa- 
sionally bestudded  with  small  ulcerations,  and  afterward,  when 
these  get  well,  the  palm  of  her  left  hand  becomes  affected  with  a 
sort  of  psoriasis  palmaris.  The  tongue  is  at  present  quite  well,  but 
the  palm  of  her  hand  is  covered  with  the  eruption.  When  this  gets 
better,  however,  she  expects  her  tongue  to  become  again  the  seat  of 
disease,  for  thus  they  have  alternated  for  a  considerable  time  past — 
she  says  about  two  years.  The  chief  reason  for  which  she  consults 
me  at  present,  however,  is  that  she  has  gout  in  one  of  her  feet.  I 
believe  that  the  whole  series  of  her  complaints  depends  on  some 
derangement  of  the  digestive  organs,  though  that  is  not  made  very 
apparent  by  external  symptoms.  I  gave  her  an  alterative  pill,  and  a 
tonic  mixture,  combined  with  colchicum  and  an  alkali.  The  gout  has 
already  disappeared,  and  even  the  hand  is  much  improved.  As  soon 
as  the  gout  was  got  rid  of  I  substituted  for  the  tonic  mixture — in 
which,  as  I  have  just  said,  were  wine  of  colchicum  and  carbonate  of 
soda — a  mixture  composed  of  the  extract  of  sarsaparilla  combined 
with  the  iodide  of  potassium.  As  a  local  application  to  her  hand  I 
prescribed  an  ointment  composed  of  pure  iodine,  iodide  of  potassium, 
and  hog's  lard  ;  but  this  was  found,  upon  trial,  to  give  her  so  much 
pain,  and  produced  so  much  irritation,  that  I  was  forced  to  abandon 
its  use  after  a  few  days'  trial.  For  it  I  substituted  the  following 
ointment,  viz. :  white  oxide  of  mercury  four  grains,  and  extract  of 
conium  a  drachm,  rubbed  up  with  seven  drachms  of  prepared  hog's 
lard.     This  ointment  was  ordered  to  be  rubbed  into  the  palm  of  her 


THE   TONGUE  AND   ITS  DISEASES.  591 

hand  every  day,  both  morning  and  evening.  Besides  those  reme- 
dies, local  and  general,  she  took  occasionally  an  alterative  and  aperi- 
ent pill,  made  up  of  blue  pill  and  the  compound  extract  of  colocynth. 
The  consequence  has  been,  after  a  month's  steady  use  of  the  reme- 
dies, that  the  hand  has  become  quite  well,  the  skin  being  now,  for 
the  first  time  these  two  years,  soft,  whitQ,  flexible,  smooth,  and  com- 
pletely free  from  itching,  heat,  and  every  unpleasant  appearance  and 
feeling.  Jv^or  has  the  tongue  as  yet  shown  any  tendency  to  alternate 
disease,  as  before ;  so  that  we  have  reason  to  hope— the  constitution 
having  been  set  to  rights  by  the  means  employed— the  former  chain 
of  morbid  sympathy  between  the  distant  organs  of  which  we  have 
been  speaking,  and  by  which  a  metastasis  of  the  psoriasis,  from  the 
one  to  the  other  alternately,  took  place  so  often,  for  so  long  a  time, 
has  been  at  last  broken  and  destroyed,  permitting  both  to  remain  in 
their  healthy  condition." 

Urticaria,  a  very  common  skin  trouble,  I  have  myself  met  with  as 
having  a  similar  metastatic  relation.  In  this  case  a  wheal  would 
appear  either  upon  the  cheek  or  the  tongue  whenever  ice-cream  was 
eaten. 

Hypertrophy. — This  condition  has  been  met  with  and  described 
by  various  writers.  Hypertrophy  may  be  complete,  involving  the 
whole  organ,  or  the  enlargement  may  pertain  to  particular  tissues 
alone.  A  case  is  described  by  Mr.  Paget,  involving  the  muscular 
substances  exclusively,  the  primitive  fasciculi  being  found  to  divide 
in  a  dichotomous  manner.  The  epithelium  is  another  of  the  tissues 
most  frequently  found  affected,  instances  being  on  record  where  this 
structure  has  thickened  so  as  to  resemble  a  coat  of  mail.  Granular 
hypertrophy,  a  condition  of  enlargement  of  the  papillary  structure, 
is  sometimes  seen  in  the  form  of  a  mass  of  warty  excrescences  cover- 
ing the  whole  body  of  the  tongue  ;  at  other  times  it  is  confined  to 
some  portions,  more  or  less  limited  in  extent. 

The  treatment  of  a  hypertrophied  tongue  must  be  governed  by  the 
circumstances  and  character  of  each  particular  case.  In  epithelial 
hypertrophy  the  best  results  seem  to  have  been  secured  through  the 
use  of  arsenic, — from  the  thirtieth  to  the  twentieth  of  a  grain  being 
administered  three  times  a  day,  its  efiect  being  carefully  noted. 
Donovan's  solution,  the  liq.  hydrarg.  arson,  et  iod.,  given  in  five- 
drop  doses,  has  been  highly  commended. 

In  granular  or  papillary  hypertrophy,  the  use  of  chromic  acid  will 
be  found  desirable,  touching  the  various  excrescences  daily  with  the 
crystals.     Another  excellent  application  is  the  solution  of  the  per- 


I 


592  ORAL  DISEASES  AND   SURGERY. 

chloride  of  iron.  Cvitting  the  warts  away  in  mass,  by  the  use  of  a 
pair  of  scissors,  may  be  practiced  where  the  parts  are  not  too  vascu- 
lar.    Pyroligneous  acid  is  another  favorite  means  of  cure. 

In  a  true  hypertrophy  of  the  organ — that  is,  where  the  body  has 
enlarged,  as  a  result  of  congenital  impressions — medicinal  appliances 
are  of  little  service.  This  disease  is  markedly  one  of  young  life, 
commencing  generally  very  soon  after  birth,  and  progressing  tardily 
but  surely  until  death  or  an  operation  gives  relief.  Unaccountable 
though  it  may  seem,  hypertrophy  is  confined  almost  exclusively  to 
female  children, — this  sex  being  affected  in  the  proportion  of  five  to 
one. 

As  may  be  inferred,  hypertrophy  of  the  tongue  .presents  various 
degrees  of  enlargement, — cases  being  on  record  where  the  organ  has 
hung  from  the  mouth,  resting  upon  the  breast.  In  the  cases  of  ele- 
phantiasis, the  raucous  membrane  looks  more  like  the  bark  of  a  tree 
than  anything  else,  being  rough,  dry,  and  crusted. 

In  the  treatment  of  hypertrophy,  we  consider  the  character  of  the 
trouble  from  the  twofold  aspect  of  activity  and  chronicity.  Where 
the  first  of  these  characters  exists,  much  may  be  hoped  for  from  medi- 
cation ;  where  the  latter  obtains,  little  may  be  expected  except  from 
operation. 

Compression,  as  recommended  by  Lasser  and  indorsed  by  Prof 
Syme,  it  may  not  be  amiss  to  try  before  proceeding  to  excision  ;  but 
the  treatment  will  certainly  be  found  to  have  much  more  of  failure 
than  of  success  in  it. 

Excision  of  the  Tongue. — From  surgical  necessit}^,  or  from 
accident,  it  sometimes  becomes  necessary  to  amputate  a  part  or 
even  the  whole  of  the  tongue.  Surprising  as  it  may  seem,  such 
amputations,  even  when  of  the  complete  organ,  interfere  very 
little  with  the  speech,  and  do  not  entirely  obliterate  the  sense  of 
taste.  Mr.  Xunnely,  an  English  surgeon,  lately  exhibited  to  the 
Pathological  Society  of  London  a  patient  from  whom  he  had  re- 
moved the  whole  of  the  organ ;  this  being  effected  by  a  submental 
opening ;  the  patient,  a  man  aged  thirty-five,  never  having  a  bad 
symptom.  The  disease,  which  had  existed  sixteen  or  eighteen 
months,  became  worse  two  months  before  the  operation,  and  from 
the  pain  and  difficulty  of  speaking,  the  impossibility  of  mastication, 
and  difficulty  of  deglutition,  was  fast  wearing  the  patient  out.  When 
shown  to  the  society,  the  patient  had  recovered  strength  and  flesh  ; 
Indeed,  said  that  he  felt  as  well  as  ever ;  he  talked  with  great  dis- 
tinctness, and  swallowed  with  facility. 


THE   TONGUE  AND   ITS   DISEASES. 


593 


A  second  interesting  case  is  reported  by  James  Syme,  F.R.S.E 
Surgeon-in-Ordinary  to   the    Queen  in   Scotland,  and  Professor  of 
Clinical  Surgery  in  the  University  of  Edinburgh : 

"About  twelve  months  ago,"  says  Mr.  Syme,  "I  communicated 
a  case  in  which  the  tongue  had  been  completely  removed  by  exci- 
sion, on  account  of  extensive  disease  that  threatened  to  prove  fatal 
by  preventing  the  admission  of  nourishment.  This  account  was 
necessarily  limited  to  the  operation  and  its  immediate  effects,  as 
sufficient  time  had  not  elapsed  for  determining  whether  or  not  the 
relief  afforded  would  prove  permanent,  or  how  far  the  powers  of 
deglutition,  articulation,  and  taste  would  be  restored.  After  his 
return  home  to  Manchester,  the  patient  sent  me  favorable  reports  of 
his  progress,  but  certainly  not  such  as  to  convey  any  adequate  idea 
of  the  improvement  that  had  taken  place  since  he  came  under  my 
care.  He  was  then  emaciated  and  bent  down  by  long-continued 
suffering,  unable  to  articulate,  so  as  to  require  a  slate  and  pencil  for 
expressing  his  wishes,  and  swallowing  even  fluids  with  such  ex- 
treme difficulty  as  to  feel  on  the  point  of  starvation.  My  surprise 
may,  therefore,  be  imagined  when,  on  the  10th  of  September  last,  he 
unexpectedly  made  his  appearance,  erect  and  vigorous,  and,  seeing 
that  I  did  not  recognize  him,  announcing  his  name  in  a  loud,  clear 
voice.  The  feeling  thus  excited  was  not  lessened  by  learning  that, 
while  traveling  in  the  Highlands,  he  had  dined  at  table-d'hotes,  and 
entered  into  conversation  without  betraying  the  deficiency  under 
which  he  labored.  Very  much  astonished  by  a  result  so  much  better 
than  could  have  been  anticipated,  I  requested  a  number  of  my  medi- 
cal friends  to  join  me  in  examining  the  state  of  matters.  Professor 
Goodsir  and  Mr.  Nasmyth  having  satisfied  themselves  that  no 
vestige  of  the  tongue  remained,  various  observations  were  made 
with  regard  to  articulation  and  other  functions  of  the  absent  organ ; 
and  Mr.  Annandale  afterward  instituted  a  more  particular  inquiry, 
of  which  he  has  given  me  the  following  report: 

"  '  The  lips  and  jaw-bone,  where  divided,  were  soundly  united 
without  any  deformity.  The  opening  between  the  mouth  and 
pharynx  was  much  diminished  in  size  and  irregular  in  shape  from 
contraction  of  the  fauces  and  soft  palate,  which  were  drawn  downward 
and  forward  more  to  the  right  than  the  left  side,  from  the  mucous 
membrane  at  that  part  having  participated  in  the  disease  and  been 

removed  along  with  the  tongue.     Mr.   W says  that  he  can 

swallow  as  well  as  ever,  provided  that  the  food  is  either  finely 
divided  or  fluid.     He  is  also  able  to  masticate  solid  substances, 

38 


594  ORAL  DISEASES  AND  SURGERY. 

although  difficulty  is  sometimes  experienced  from  their  getting  into 
awkward  parts  of  the  mouth.  In  ordinary  speech  his  words  are 
wonderfully  clear  and  distinct,  and  he  can  sing  without  any  diffi- 
culty.  All  the  vowels  and  words  composed  of  them  are  articulated 
perfectly,  and  also  the  following  consonants :  B,  C,  F,  H,  K,  L,  M, 
N,  P,  q'  R,  Y,  W.  D  is  pronounced  "dthe,"  J  "the,"  G  like  "  sjee," 
"S"  is  a  lisp.  His  taste  is  impaired,  but  still  enables  him  to  dis- 
tinguish different  articles  and  their  respective  qualities,  as  grouse 
from  partridge,  bitters  from  sweets,  good  beer  from  bad  beer,  etc. 
He  has  remarked  that  the  seat  of  sensation  lies  somewhere  in  the 
throat,  since  there  is  no  recognition  of  taste  previous  to  the  act  of 
swallowing ;  and,  in  order  to  ascertain  the  truth  on  this  point  more 
precisely,  the  following  experiments  were  made : 

"  '  1.  A  strong  solution  of  salt  was  applied  by  means  of  a  camel's- 
hair  brush  to  the  fauces,  palate,  floor  of  the  mouth,  lips,  and  inner 
surface  of  the  cheek,  with  the  result  of  something  being  felt  in  the 
mouth ;  but  no  idea  formed  as  to  its  nature. 

"  '2.  About  a  quarter  of  a  teaspoonful  of  finely-powdered  sugar 
was  placed  on  the  floor  of  the  mouth,  and,  having  been  allowed  to 
remain  there  a  few  seconds,  was  then  brought  thoroughly  into  con- 
tact with  every  part  of  the  cavity  without  any  recognition  of  its 
nature  ;  but  when  a  little  water  was  added  and  swallowed,  the  taste 
was  immediately  perceived. 

"  '  3.  The  same  experiment  was  repeated  with  another  substance 
(salt),  and  with  the  same  result.' 

"  It  has  long  been  known  that  large  portions  of  the  tongue  may 
be  removed  without  destroying  or  materially  impairing  the  power 
of  articulation  ;  but  I  am  not  aware  of  any  case  on  record  in  which 
it  has  remained  so  perfect  after  complete  removal  of  the  organ.  Of 
the  facts  above  mentioned,  the  one  that  seems  most  curious  is  the 
connection  between  taste  and  deglutition;  from  which  it  appears 
that  the  latter  is  essential  for  the  full  perception  of  the  former.  If 
the  pleasure  of  taste  could  be  perfectly  gratified  by  mastication 
without  deglutition,  there  would  be  no  limit  to  the  consumption  of 
food;  but  the  instinctive  desire  to  swallow  an  agreeable  morsel 
affords  a  check  to  any  such  abuse." 

Mr.  Paget  reports  the  following  case : 

"  On  the  20th  of  February  a  little  girl,  about  three  years  of  age, 
was  brought  into  the  operating  theater  of  St.  Bartholomew's  Hos- 
pital with  hypertrophy  and  prolapsus  of  the  tongue,  which  com- 
menced when  she  was  some  six  months  old.     It  now  protruded 


THE   TONGUE  AND   ITS  DISEASES.  595 

nearly  two  inches,  and  hung-  downward,  completely  filling  the  circle 
of  the  lips  ;  its  end  was  dry,  and  excoriated  with  hardened  epi- 
thelium, a  sort  of  crust  having  formed  of  the  size  of  a  shilling; 
several  of  the  papillae  also  were  enlarged,  and  in  places  gave  to  the 
tongue  a  warty  or  granular  appearance.  The  lower  jaw  had  already 
begun  to  be  deformed,  and  expanded  downward  and  outward ;  the 
teeth  were  gi-adually  separating  from  one  another  in  the  mental  por- 
tion of  the  jaw  ;  and  there  was  dripping  of  saliva.  An  examination 
of  the  tongue  by  Mr.  Paget  showed  that  the  organ  was  truly  hyper- 
trophied,  and  the  part  not  prolapsed  completely  filled  the  cavity  of 
the  mouth. 

"  Chloroform  was  carefully  given  to  the  child,  and  the  chain  of  an 
ecraseur  was  passed  around  the  tongue  within  the  mouth,  the  jaws 
being  kept  open  by  a  metal  gag.  The  chain  was  slowly  drawn 
home,  and  the  prolapsed  and  hypertrophied  portion  was  detached 
with  little  or  no  bleeding. 

"  On  examination  of  the  piece  removed,  its  structure  was  found  to 
be  similar  to  that  of  the  natural  organ,  both  in  texture  and  color;  it 
was  simply  a  redundancy  of  growth,  from  hypertrophy. 

"  The  subsequent  progress  of  the  case  was  reported  as  most  satis- 
factory, a  good  recovery  being  recorded." 

Partial  amputations  of  the  tongue  have  been  very  frequent.  Union, 
in  many  of  the  cases,  is  very  rapid  and  perfect.  In  one  case,  that  of 
a  child,  where  a  kind  of  a  flap  operation  was  made,  I  got  reliable 
union  in  a  single  day,  and  never  had  trouble  with  it  afterward. 

Subfig.  1,  in  plate,  is  a  front  view  of  the  anatomical  relations  of 
the  parts  about  the  fauces  as  shown  with  the  mouth  widely  open.  1, 
the  dorsum  of  the  tongue;  2,  3,  the  tonsils;  4,  the  uvula;  5,  the 
anterior  half  arch;  6,  the  posterior  half  arch,  with  the  tonsil  between 
it  and  5  ;  7,  the  soft  palate. 

Subfig.  2  represents  a  side  view  of  a  vertical  section  of  the  mouth 
and  tongue,  showing  the  relations  of  the  vessels  and  nerves  of  the 
tongue.  1,  the  lingual  artery;  2,  its  sublingual  branch, — the  veins 
accompanying  the  arteries;  3,  the  hypoglossal  nerve;  4,  the  ranine 
terminations  of  the  lingual  vessels. 

Subfig.  3  represents  the  situation  and  associations  of  a  disease 
compelling  amputation  of  a  section  of  the  tongue.  The  lines,  1,  2, 
3,  form  a  Y,  which  is  to  circumscribe  the  groAvth;  it  should,  how- 
ever, have  been  placed  much  farther  back. 

Subfig.  4  exhibits  the  operation  of  excising  the  tongue,  as  prac- 
ticed with  scissors.   When  the  knife  is  used,  the  sections  are  similarly 


596  ORAL  DISEASES  AND  SURGERY. 

made.  If,  in  such  an  operation,  the  hemorrhage  is  threatening,  it  is 
better  to  quickly  ligate  the  vessels  of  one  side  before  making  the 
section  of  the  other ;  this  suggestion,  however,  only  holds  good  when 
the  bleeding  orifices  are  freely  exposed,  and  can  be  reached  without 
effort  or  difficulty. 

Subfig.  5  shows  the  preceding  operation  completed,  and  the  flaps 
united  by  ligatures.  1,  2,  represents  the  sutures, — wire  pins  or  waxed 
silk  may  be  used.  Let  them  be  left  in  only  long  enough  to  secure 
the  union;  this,  if  no  undue  inflammation  supervenes,  will  be  ac- 
complished in  from  twenty-four  to  forty-eight  hours. 

Subfig.  6  is  the  lingua  vitula,  or  lingual  hypertrophy.  The  par- 
ticular case  here  represented  was  a  patient  of  Dr.  Harris,  of  Phila- 
delphia, and  was  the  first  operation  performed  in  the  United  States. 
The  case  is  thus  described  by  Prof.  Smith  in  his  System  of  Surgery. 

"The  patient,  aged  nineteen,  had  the  tongue  enlarged  at  birth.  A 
short  time  previous  to  the  operation  it  projected  beyond  the  upper 
incisors  at  least  three  inches.  Its  circumference  was  six  inches,  and 
its  vertical  thickness  one  inch  and  a  half;  it  filled  up  the  jaws  so 
completely  that  it  was  necessary  to  have  his  food  cut  into  small 
pieces  and  introduced  at  the  side  of  the  tongue." 

The  operation  practiced  by  Dr.  Harris  was  accomplished  as  fol- 
lows: "The  tongue  being  elevated,  a  strong  ligature  was  passed 
through  its  top  so  as  to  control  its  movements.  The  under  surface 
was  then  dissected  from  the  floor  of  the  mouth  about  three-fourths 
of  an  inch  behind  the  anterior  part  of  the  jaw,  and  a  strong,  straight 
bistoury  introduced  into  the  organ  at  a  point  where  the  dissection 
terminated,  whence  it  was  pushed  through  between  the  median  line 
and  the  left  ranine  artery,  and,  being  drawn  laterally  and  forward, 
was  made  to  cut  a  flap,  which  terminated  near  the  first  bicuspid 
tooth.  The  left  ranine  artery  being  then  secured  with  a  ligature,  the 
bistoury  was  again  introduced  in  a  corresponding  position  on  the 
right  side,  and  the  opposite,  or  right  flap,  made  in  a  similar  manner. 
The  artery  of  this  side  being  now  secured,  and  the  space  interven- 
ing, or  central  portion,  divided  by  strong  scissors,  the  incisions  or 
flaps  resembled  the  letter  V,  and,  being  approximated  by  these  in- 
terrupted sutures,  made  a  pointed,  well-formed  tongue  of  the  ordi- 
nary length.  A  year  subsequently,  the  patient  articulated  distinctly, 
and  was  relieved  of  all  deformity." 

In  another  case,  somewhat  similar  to  this,  under  the  care  of  the 
same  surgeon,  a  ligature  was  applied  to  the  enlarged  portion,  in 
order  to  cause  it  to  slough  oS";  but  the  irritation.  Professor  Smith  in- 


THE    TONGUE  AND    ITS  DISEASES.  597 

forms  us,  was  so  great  that  Dr.  Harris  found  himself  subsequently 
compelled  to  amputate  the  end  of  the  tongue  with  a  catlin.  In  this 
patient  the  organ  protruded  four  inches ;  its  circumference  was  over 
six  inches,  and  its  vertical  thickness  nearly  two  inches. 

The  subfigures  1  and  8  represent  the  "amputation  of  the  ton.«il 
gland  with  the  knife,  and  with  the  tonsiflotome.  (See  Tonsil  Gland.'^.) 

ToNGUE-TiE.— The  condition  denominated  tongue-tie  is  frequently 
met  with  in  young  children,  and,  indeed,  occasionally  in  the  adult. 
Tongue-tie  is  simply  a  shortening  or  curtailment  of  the  anterior 
mucous  fraenum.  A  tongue  that  cannot  be  projected  beyond  the 
teeth  is  tied,  and  a  tongue  so  tied  cannot  perform  its  various  offices 
comfortably  and  naturally.  In  examining  the  mouth  of  a  child  thus 
afflicted,  the  tip  of  the  tongue  will  not  unfrequently  be  found  drawn 
down  and  fixed  to  the  floor  of  the  mouth,  incapable,  indeed,  of  anv 
movement.  These,  however,  are  extreme  cases,  the  usual  condition 
being  simply  curtailment  of  natural  motion. 

Tongue-tie  is  of  two  kinds,  adventitious  and  congenital.  Of  the 
first,  that  arising  from  ulceration  is  the  most  common.  A  person 
having  a  bad  ulcer  under  the  tongue,  particularly  if  on  the  side  of 
the  fraenum,  is  almost  sure  to  have  this  fold  shortened  as  the  result 
of  cicatrization. 

A  second  form  is  one  described  by  Professor  Dewees,  exceedingly 
rare,  I  imagine,  but  worthy  of  note. 

"Very  frequently,"  says  Professor  Dewees,  "there  is  attached  to 
the  fri"enum  of  the  tongues  of  new-born  children  a  nearly  transpa- 
rent, whitish  membrane,  Avhich  pursues  the  natural  frsEnum  through 
its  whole  course,  continues  beyond  the  point  where  the  frajnum  stops, 
and  terminates  near  the  extremity  of  the  tongue  itself;  so  that  the 
tongue  is  tied  down,  as  it  were,  to  its  proper  bed. 

"  In  consequence  of  this  disposition  of  the  frgenum,  the  cliild  can- 
not elevate  the  tongue  or  protrude  it  beyond  the  lips ;  and  in  its 
attempts  to  suck,  it  cannot  apply  it  with  sufficient  force  or  cer- 
tainty to  the  nipple  to  make  a  complete  exhaustion  ;  therefore  it 
can  suck  but  imperfectly;  and  this  is  accompanied  by  a  clucking 
kind  of  noise.  Whenever  this  is  observed,  the  mouth  should  be  ex- 
amined, and  it  will  almost  always  be  found  in  the  situation  just 
described ;  but  not  necessarily,  as  there  may  be  clucking  without 
this  membrane ;  but  this  membrane,  we  believe,  is  never  without 
the  clucking. 

"  This  membrane  is  easily  discovered  by  provoking  the  child  to 
cry,  or  by  elevating  the  point  of  the  tongue  by  the  extremity  of  the 


698  ORAL   DISEASES  AND  SURGERY. 

little  finger.  In  making  the  attempt  to  raise  the  tongue,  the  child 
is  almost  sure  to  cry ;  and  then  this  membrane  is  readily  discovered, 
as  it  is  now  fully  upon  the  stretch. 

"  This  defect  is  easily  remedied.  It  should  be  done  in  the  follow- 
ing manner :  let  the  child  be  laid  across  the  lap  of  the  nurse,  with 
its  face  toward  a  proper  light,  and  the  operator  stand  behind  the 
head,  so  that  he  does  not  intercept  the  light.  The  chin  of  the  child 
must  be  gently  depressed  by  the  forefinger  of  the  nurse.  When  the 
chin  is  thus  depressed,  the  little  finger  of  the  left  hand  of  the 
operator  must  be  insinuated  between  the  side  of  the  tongue,  near  its 
tip,  and  the  inner  corresponding  portion  of  the  jaw,  until  it  can  lift 
up  the  point  of  the  tongue ;  which  being  done,  the  membrane  is  im- 
mediately brought  into  view,  and  upon  the  stretch ;  or,  should  the 
child  now  begin  to  cry,  as  it  almost  always  does,  the  operator  can 
easily  place  his  finger  under  the  tongue,  and  keep  this  false  fraenum 
tense,  while,  by  a  single  stroke  directly  across  it  by  a  sharp  gum 
lancet,  he  divides  it  to  the  true  fraenum:  the  operation  is  then  fin- 
ished. We  have  never  known  it  necessary  to  repeat  this  operation. 
The  incision  through  the  membrane  never  yields  more  than  a  small 
drop  of  blood ;  no  hemorrhage  can  ensue,  as  this  tissue  is  but  very 
slightly  vascular." 

A  third  of  the  adventitious  forms  is  the  result  of  the  induration 
of  the  fraenum.  This  is  occasionally  venereal  in  character,  but  more 
frequently  carcinomatous.  In  these  cases  the  band  gradually  thick- 
ens until  the  motion  of  the  tongue  is  markedly  impaired.  The  can- 
cerous is  distinguished  in  its  incipiency  from  the  venereal  disease 
by  the  greater  pain  associated  with  the  movements  of  the  parts :  in 
the  first,  the  pain  is  acute  and  sharp ;  in  the  second,  it  is  soreness 
rather  than  pain.  If  the  induration  is  malignant,  the  parts  may  be 
excised,  but  a  hope  of  cure  is  very  slight ;  if  venereal,  we  pursue 
the  specific  treatment  conjoined  with  such  general  and  local  combi- 
nations as  may  seem  demanded  by  the  particular  case.  Donovan's 
solution,  given  in  five-drop  doses,  is  quite  reliable ;  the  practitioner 
is  to  avoid  overirritation  to  the  fraenum. 

Congenital  tongue-tie  is  quickly  appreciated  by  lifting  the  tip  of 
the  organ.  These  cases  differ  very  much,  the  fraenum,  at  times, 
being  observed  to  run  as  in  the  normal  course,  except  that  it  is 
much  shortened.  In  other  instances  the  fold  passes  forward  almost 
to  the  apex.  This  fold  may  be  free  or  tight.  If  the  former,  it  forms  a 
septum  between  the  lateral  aspects  of  the  floor  of  the  mouth,  but  is 


THE   TONGUE  AND   ITS  DISEASES.  599 

not  otherwise  inconvenient;  if  the  latter,  it  ties  the  tongue  more  or 
Jess  closely. 

The  relief  of  a  congenital  tie  consists  in  nicking  or  cutting  the 
contracted  franum.  This  operation,  although  of  the  simplest  nature 
requn-es  to  be  performed  with  some  care.  A  frseuum  too  freely  cut 
will  permit  of  the  tongue  being  pulled  quite  far  back  into  the  fauces  • 
cases  being  on  record  where  suffocation  has  nearly  resulted  from' 
such  accidents.  Again,  it  is  not  to  be  forgotten  that  the  ranine 
vessels  inosculate  just  in  front  of  the  frsenum  on  the  under  surface 
of  the  tongue,  and  might  very  easily  be  divided  in  an  operation, 
many  children  having  lost  their  lives  from  such  an  accident. 

A  proper  operation  consists  in  making  a  simple  nick  midway  Ijc- 
tween  the  tongue  and  the  floor  of  the  mouth  :  a  rupture  of  the'part 
thus  secured,  the  motions  of  the  tongue  will  quickly  secure  all  the 
latitude  required.  Should  an  operation,  unfortunately,  open  a  ves- 
sel, the  best  practice  would  be  to  secure  it  with  a  ligature :  this, 
unfortunately,  is  not  always  easy  to  be  accomplished,  the  artery 
retracting  within  its  loose  sheath.  A  mode  devised  by  M.  Petit  to 
control  such  a  hemorrhage  consists  in  taking  a  piece  of  ivory,  cut 
fork-shape — the  prongs,  of  which  there  are  two,  passing  on  either 
side  of  the  fraenum,  the  short  handle  resting  against  the  inside  of 
the  jaw.  To  apply  this  instrument,  introduce  against  the  bleed- 
ing vessel  a  tuft  of  lint  saturated  with  alum-water,  or  other  astrin- 
gent ;  place  now  the  fork  about  it,  and  secure  it  in  place  by  pressing 
it  down  with  the  tongue,  over  and  around  Avhich,  and  the  jaw,  a 
roller  is  to  be  thrown. 

Swallowing  the  tongue,  as  it  is  called,  is  a  disagreeable  accident, 
and  may  occur  without  section  of  the  fraenum.  Dr.  Dewees  men- 
tions one  case  in  which  a  child  became  choked  several  times  a 
day  from  such  a  recession.  It  was  always,  however,  relieved  by 
the  nurse,  w^ho  would  press  the  organ  down  with  the  handle  of  a 
spoon  and  then  draw  it  forward.  A  second  case,  reported  by  Pro- 
fessor Gross,  resulted  in  the  death  of  the  child  at  eighteen  months. 

To  operate  for  tongue-tie,  it  is  best  to  place  the  body  of  an  infant 
upon  the  lap  of  the  nurse,  the  head  being  received  upon  or  between 
the  knees  of  the  surgeon ;  the  tip  of  the  tongue  is  now  raised,  and 
the  cut,  or  nick,  made  with  a  pair  of  curved  scissors. 


CHAPTER    XXXV  III. 


THE   APHTHiE. 


Aphtha  is  a  term  which  every  reader  must  have  remarked  to  be 
associated  (like  the  word  epulis)  with  some  degree  of  confusion. 

In  the  Greek,  from  which  the  term  is  derived,  there  are  two 
verbs  with  the  same  spelling — a--io.  The  meaning  of  the  one  is 
"to  set  on  fire;"  that  of  the  other,  "to  bind  to"  or  "to  fasten 
upon." 

The  mouth  presents  ulcers  or  sores  of  various  signification, — 
some  which  are  characterized  by  pain  of  a  burning,  inflammatory 
character;  others,  chronic,  or  cold  in  nature,  furnish  an  inviting 
soil  to  a  very  persistent  and  almost  omnipresent  parasite — the 
oidium, — this  fungus  fastening  upon  and  binding  such  sores  in  its 
necklace-like  embrace.  It  has  thus  very  naturally  occurred  that 
pathologists,  seeking  an  expressive  term  by  which  to  designate 
these  varying  conditions,  differently  employed  the  common  name  as 
it  happened  to  them  to  observe  or  adopt  the  one  or  the  other  of  the 
roots  from  which  the  expressions  were  derived.  That  such  uses  of 
the  dissimilar  verbs  on  the  part  of  various  authors  must  have  been 
made,  is  necessary  to  be  inferred  to  explain  the  differences  which 
characterize  their  descriptions. 

With  such  examples  of  libert}',  intentional  or  unintentional,  I 
may  be  excused  in  presenting  to  my  readers  the  subject  after  my 
own  manner  and  views 

For  the  reasons  of  the  double  derivation,  and  for  others  which  I 
shall  proceed  to  present,  the  term  aphthfe  cannot,  injustice  and  patho- 
logical signification,  be  applied  to  a  particular  species  of  sore,  but 
must,  as  a  noun  of  multitude,  apply  to  a  class — which  class  has 
many  species.  Thus  we  may  accept  as  explained  and  dismissed  the 
various  questions  of  ulceration  and  non-ulceration,  exudation  or  non- 
exudation,  the  oidium  or  no  fungi. 

The  type  of  aphthae  is  as  follows :  An  aphtha  or  aphthous  patch 
is  a  degenerate  sore,  to  be  seen,  under  varying  circumstances,  upon 
the  mucous  surface  of  the  mouth,  the  fauces,  the  oesophagus,  and, 
(600) 


THE  APHTHA.  gQj 

quite  likely,  upon  any  part  of  the  alimentary  canal,  and  perhaps  as 
well  the  respiratory  tract.  The  most  common  seat  of  this  patch  is  the 
uvula  ;  next  to  this  the  lower  lip  ;  next  the  tongue.  The  sore  varies 
in  size,  from  the  smallest  point  to  a  confluent  mass  which  may 
cover  a  large  surface  ;  looks  pasty  or  exudative,  is  generally  ob- 
long  in  shape,  and  varies  in  color  from  the  misty  white  of  hoar- 
frost to  the  dirty-yellow  of  scrofulous  pus.  As  most  frequently 
seen,  such  a  patch  is  one  of  perhaps  several  similar  sores. 

This,  as  described,  is  the  type  case.  From  it  we  are  prepared  to 
pass  to  the  general  view  of  the  subject. 

An  aphtha  is  a  canker  ;  nothing  more,  nothing  less.  Thrush,  fol- 
lieular  inflammation,  cancrum  oris,  gangrsena  oris,  are  all  species  of  a 
cancroid  class,  of  the  class  aphthse. 

What,  then,  is  aphthse  ? 

The  modern  microscopist  exhibits  and  describes  aphthse  as  patches 
of  a  fungoid  excrescence — the  oidium  albicans.  A  pot  of  paste,  a 
papered  wall,  a  section  of  apple  or  other  fruit,  the  leather  back  of  a 
book  or  chair,  exposed  to  a  confined  atmosphere,  hot  and  moist, 
quickly  enough  produces,  or  rather  gives  attachment  to,  the  oidium. 

Oidium  albicans  is  not  a  disease,  is  not  aphtha ;  neither  is  it  the 
expression  of  disease.  It  is  merely  a  fungous  growth,  accidentally 
associated  with  a  soil  and  circumstances  favorable  to  it  as  a 
habitat.* 

Aphthae  is,  without  doubt,  the  expression  of  a  cachexia,  and  is 


*  Parasitic  fungi  (Hogg  on  the  Microscope),  vegetable  blights  as  they  are 
commonly  called,  have  of  late  years  become  objects  of  earnest  attention,  on 
account  of  the  enormous  damage  done  to  our  growing  crops,  and  also  of  the 
many  curious  facts  in  their  historj'-  which  have  been  brought  to  light. 
Oidium  is  a  common  mildew. 

It  appears  that  at  particular  periods  of  the  year  the  atmosphere  is,  so  to 
speak,  more  fully  charged  with  the  various  spores  of  fungi  than  it  is  at  others. 
In  1854,  the  Eev.  Lord  Godolphin  Osborne,  during  the  cholera  visitation, 
exposed  prepared  slips  of  glass  over  cesspools,  gully-holes,  etc.  near  the  dwell- 
ings of  those  where  the  disease  appeared,  and  caught  what  he  termed 
aerozoa, — chiefly  minute  spores  and  germs  of  fungi. 

From  this  same  year  (1854)  to  the  present  time,  we  have  amused  ourselves 
by  catching  these  floating  atoms,  and,  so  far  as  we  can  judge,  they  are  found 
everywhere,  and  in  and  on  every  conceivable  thing,  if  we  only  look  closely 
enough  for  them.  Even  the  open  mouth  is  an  excellent  trap.  Of  this  there 
is  ample  evidence,  since  we  find  on  the  delicate  membrane  lining  the  mouth 
of  the  sucking,  crying  infant,  and  on  the  diphtheritic  sore-throat  of  the  adult, 
the  destructive  plant  oidium  albicans. 


602  ORAL  DISEASES  AND  SURGERY. 

not  likely  to  be  a  merely  local  disease.  Neither,  I  conceive,  is  it 
possible  for  the  fungus  to  be  peculiar  to  a  sore,  as  a  something 
specific,  any  more  than  it  is  peculiar  to  the  paste,  the  fruit,  or  the  book. 
It  depends  in  the  one  instance,  as  in  the  other,  upon  an  accidental 
association.  This  accident,  in  the  case  of  the  sore,  is  the  absence  of 
a  sufficient  vitality  to  enable  a  part  to  resist  the  "fastening  upon 
itself"  of  ever-present  parasites.  The  microscopist,  if  I  may  be 
allowed  to  suggest  it,  has,  in  his  examinations  and  conclusions, 
accepted  the  accident  and  overlooked  the  true  disease. 

Thrush  or  miiguet,  one  of  the  species,  is  an  erythematic  inflamma- 
tion, degenerating  after  a  few  days  into  a  condition  of  curdy  exuda- 
tion. The  inflamed  surface,  after  a  longer  or  shorter  time,  presents 
small  whitish  points ;  these  coalesce,  forming  the  exudate  patches. 
These  patches  vary  in  color ;  as  they  remain  moist  and  clear,  they 
are  considered  with  least  apprehension  ;  as  they  grow  dry  and 
brown,  they  are  esteemed  possessed  of  dangerous  import. 

Dissections  of  the  cadaver  have  exhibited  aphthae  not  only  upon 
the  oesophageal  mucous  membrane,  but  also  on  other  parts  of  the 
alimentary  canal.  They  have  not  as  yet,  so  far  as  I  am  aware,  been 
met  with  upon  the  respiratory  tract ;  but  there  is  no  good  reason 
why  they  should  not  have  here  a  like  existence. 

In  an  acute  attack  of  thrush  the  mouth  is  hot  and  the  general 
condition  feverish.  Milder  cases,  or  those  of  easy  progress,  seem — 
so  far  as  any  observable  constitutional  sympathy  is  concerned — to 
have  alone  a  local  signification. 

But,  if  thrush  is  a  distinct  disease,  could  it  be  possessed  of  a  dou- 
ble signification  ?  Could  it  at  one  time  be  strictly  local,  at  another 
systemic  ?  Thrush  is  common  to  children  prematurely  born  or 
nursed  by  unhealthy  women.  It  belongs  to  hot,  moist  climates,  to 
the  situations  of  uncleanly  hospitals ;  in  fact,  to  any  and  every  con- 
dition deemed  to  be  depressive  of  the  life-force ;  it  is,  in  short,  a  sys- 
temic adynamic  expression,  seated  on  a  mucous  surface.  That  it 
differs  from  carbuncle  or  cancrum  oris  is  not  the  case  in  fact,  but 
only  in  degree  ;  it  is,  in  other  words,  one  expression  of  a  common 
condition, — a  species,  and  not  a  class. 

Follicular  inflammation — another  form  of  stomatitis  very  likely 
to  be  asthenic — is  a  term  used  to  signify  that  the  abnormal  vascu- 
lar change  is  seated  in  the  mucous  crypts  or  follicles.  In  passing 
the  finger  over  a  surface  so  inflamed,  the  studded  irregularity  pro- 
duced by  the  engorgement  of  the  glands  is  plainly  evident.  As 
such  inflammation  progresses,  the  bodies  become  recognized  by  the 


THE  APHTHA.  g^^ 

eye  as  papular  eminences  standing  out  from  a  common  erythematic 
surface.  In  color  they  are  of  a  varying  red,  such  variations  in  shade 
expressing  the  constitutional  conditions. 

Follicular  inflammation  terminates  either  bv  resolution  or  ulcera- 
tion ;  when  in  the  latter  way,  the  follicles  soften  in  the  center,  sup- 
purate, and  have  the  bottom  filled  with  a  whitish,  pasty  mass ;  when 
in  this  condition,  they  are  the  aphthiB  of  M.  Billard. 

Follicular  inflammation  appears  most  frequently  in  the  infont 
during  the  dentitional  period,— an  explanation  existing  in  a  quickly 
and  easily  recognized  combination  of  a  predisposition  and  an  exci- 
tant. In  its  most  simple  form,_that  is,  where  there  is  no  marked 
dyscrasis,  or  where  the  excitant  is  not  of  sufficient  intensity  to  irri- 
tate to  any  extent,— the  lancing  of  the  gums,  or  the  application  of 
cooling  local  remedies,  may  be  sufficient  to  combat  or  control  the 
manifestations.  Where,  on  the  other  hand,  the  conditions  predi.s- 
posing  to  the  disease  exist  in  a  state  of  balance,  as  it  were,  with  the 
natural  resistive  forces,  the  addition  of  a  second  depressant  influ- 
ence, as  that  resulting  from  the  irritation  of  dental  development, 
may  very  well  be  understood  as  giving  the  mastery  to  an  agent  or 
condition  otherwise  controlled  or  held  fully  in  check.  Thus  we 
explain  to  ourselves  the  real  and  apparent  connection  of  dental  irri- 
tation with  the  aphthas. 

From  a  simple  form,  or  the  inflammation  of  isolated  follicles,  the 
condition,  in  some  ill  states  of  the  general  system,  becomes  conflu- 
ent, such  extreme  form  being  most  frequently  noticed  in  the  typhoid 
exanthems,  or  in  destructive  organic  diseases.  In  confluent  follicu- 
lar inflammation,  a  prognosis  can  only  be  justly  made  when  every 
associate  and  collateral  influence  has  been  appreciated.  The  condi- 
tion will  nearly  always  be  found  an  occasion  for  anxiety. 

Caucrum  oris,  a  species  of  stomatitis,  generally  accorded  a  special 
classification,  differs  in  no  wise  from  that  just  considered,  except  in 
being  more  localized,  as  if  the  force  of  the  influence  had  concentrated 
rather  than  diffused  itself. 

The  complaint  known  as  cancrum  oris  is  an  asthenic,  spreading 
ulcer.  In  appearance  this  ulcer  differs  from  what  has  been  given 
the  special  definition  of  aphthae  by  most  writers,  only  in  being  more 
depraved  and  threatening.  It  has  the  same  pasty  bottom  of  vary- 
ing shades  of  white,  the  same  association  of  pain,  the  same  variation 
in  persistence.  Like  other  aphthas,  cancrum  oris  seems  to  be,  and  is, 
associated  with  dyscrasis,  appearing  most  commonly  in  the  infants 
of  ill-conditioned  charities,  in  the  ill  housed  and  poorly  fed,— having, 


604  ORAL  DISEASES  AND   SURGERY. 

in  all  systemic  associations,  the  precise  history  of  the  species  alluded 
to  as  thrush  and  glandular  inflammation. 

This  form  of  stomatitis,  although  confined  to  no  exact  locality,  is 
yet  most  commonly  met  with  on  the  checks  or  gums.  It  may  com- 
mence with  a  phagedenic  impression,  and  very  quickly  destroy  the 
patient ;  or  a  slight  vesicle  or  pustule  may  fir.st  appear,  to  be  fol- 
lowed bv  varying  inflammatory  associations,  precisely  as  if  some 
local  poison  was  the  source  of  the  trouble. 

The  history  of  cancrum  oris  difi'ers  from  that  of  other  cancroid 
affections  alone  in  degree.  This  is  fully  proven  in  the  facts  that  it  is 
associated  with  the  same  causes ;  that  any  ordinary  canker  sore  is 
capable  of  taking  on  an  ulcerative  action ;  that  the  fungus  oidium  is 
quite  as  common  to  the  seat  of  this  as  the  other  affections.  In  fact, 
every  analogy  will  demonstrate  that  the  relation  is  like  that  which 
associates  the  phagedenic  with  the  simple  venereal  sore,  being  the 
difference  of  degree  and  not  cause  or  character. 

Gangragna  oris,  sloughing  phagedsena,  is  another  degree  or  species 
of  the  common  class.  It  may  commence  as  an  acute  inflammation, 
quickly  deteriorating,  as  a  species  of  fatty  degeneration  of  the  epi- 
thelial tissue,  as  a  submucous  effusion,  or  as  an  eschar  which  falls 
from  its  relations  with  a  rapidity  which  leaves  us  at  a  loss  for  an 
explanation,  except  on  the  inference  that  the  materies  morbi  have  had 
the  most  special  concentration.  The  eschar,  formed  sooner  or  later, 
is  ashy  in  color,  or  a  deadish  brown,  while  the  still  living  parts, 
particularly  the  external  cheek,  if  this  part  should  be  the  seat  of  the 
ulcer,  has  an  erysipelatous  blush, — white,  semi-livid,  and  threaten- 
ing in  appearance. 

Gangrsena  oris  is  markedly  a  disease  of  the  dentitional  period, 
occurring  in  ill-fed,  ill-clothed,  or  ill-housed  children,  between  the 
first  and  second  dentitions.  Most  conspicuous  is  the  constitutional 
nature  of  this  affection.  It  is,  it  seems  to  me,  a  general  febrile  or 
inflammatory  disturbance,  concentrating  its  greatest  force  upon  some 
part  of  the  oral  cavity,  invited  or  directed,  without  doubt,  by  the 
irritability  therein  existing, — proof  of  which  inference  lies  in  the 
fact  that  in  nearly  every  case  we  find  inflammatory  complications, 
such  associated  inflammations  being  most  frequently  found  in  the 
lung-tissue.  I  take  it  for  granted  that  the  oral  concentration  saves 
some  other  more  important  part. 

Gangrgena  oris,  where  it  does  not  too  quickly  kill  and  separate 
its  eschar,  affords  support  to  parasitic  fungi ;  the  oidium  albicans,  as 
in  the  other  forms  of  aphthae,  being  that  most  frequently  met  with. 


THE  APHTHA.  ^^^ 

Oral  gangrene  varies,  as  would  be  inferred,  in  degree ;  thus,  com- 
mencing as  a  single  canker  sore,  or  epith(!lial  degeneration,  and 
terminating  with  no  very  serious  result,  it  might  be  described  as 
the  follicular,  or  other  of  the  simple  species.  Concentrated,  or  in 
its  malignant  form,  it  destroys  life  without  affording  the  physician 
any  extended  chance  to  combat  with  it.  In  healthy  children  gan- 
grene is  very  uncommon,  the  ordinary  canker  being  generally  the 
worst  manifestation.  In  children  exhausted  under  the  exanthems, 
in  those  maltreated  with  mercury,  or  laboring  under  a  syphilitic  de- 
generation, the  marked  or  destructive  type  is  exhibited. 

The  decomposition  of  mucus,  or  the  debris  remaining  from  the 
food,  when  lodged  upon  an  aphthous  sore,  forms  the  best  nidus  for 
the  development  of  fungi — it  is,  as  it  were,  a  soil — and  it  is  unde- 
niable that  epithelial  scales  in  varying  states  of  abnormal  degenera- 
tion, inspissated  mucus,  and  particles  of  decomposed  food  arc 
common  to  all  such  sores.  Thus,  in  sickly  children,  the  fungoid 
association  is  most  common  from  the  fact  of  the  weakened  energy 
of  the  parts  afflicted ;  this,  favoring  decomposition  and  the  reten- 
tion of  the  debris  in  the  cavity  of  the  mouth,  and  consequently  pro- 
ducing the  required  soil  or  habitat  of  the  oidium,  as  alluded  to. 

In  foundling  hospitals,  where  the  sucking-bottle  is  used,  the  spores 
of  fungus  find  an  easy  passage  to  the  mouth,  being  in  this  way 
located  and  developed.  In  the  nursing  infant  of  an  uncleanly 
mother,  the  accumulation  and  retention  of  the  milk  will,  with 
favoring  atmospheric  influences,  quickly  develop  fungi.  It  is  the 
fungus  and  not  aphthae  that  is  contagious,  as  must  be  plainly  seen ; 
hence  one  can  but  wonder  at  the  disputes  of  Guersant,  Billard, 
Yalleix,  Duges,  and  others. 

Review. — Having  thus  expressed  my  own  views  of  aphthae,  com- 
mitting myself  to  the  admission  that  I  fail  to  distinguish  it  as  any 
special  disease,  I  may,  with  perhaps  a  greater  justice  to  the  sub- 
ject,  present  the  opinions  of  others  whose  extended  observations 
and  judgment  have  long  held  them  in  the  light  and  i)osition  of 
authority.  Trousseau  and  Delpech  both  describe  the  aphthte  as  being 
sores  with  the  raateries  morbi  deposited  beneath  the  ei)ithelium. 
Bamberger  {Krankheiten  der  Mund  und  Mundlwle :  see  Virchow, 
Archives)  controverts  these  views,  and  explains  the  presence  of  the 
soormasse  by  the  fact  that  it  has  insinuated  itself  between,  among, 
and  below  the  epithelial  particles. 

If  we  take,  says  Professor  Bamberger,  the  soormasse,  and  place 
it  under  the  microscope,  we  find  it  made  up  almost  exclusively  of 


606  ORAL  DISEASES  AXD   SURGERY. 

epithelial  scales,  old  and  young,  the  debris  of  the  food,  and  of  in- 
spissated mucus,  which  last  is  probably  only  a  condition  of  epithe- 
lial formation.  The  color  of  the  mass  is  not  to  be  hastily  judged, 
as  this  might  have  been  influenced  by  the  debris  of  the  mouth. 

"Upon  these  sores,  however,  very  quickly  appear  a  peculiar 
organization,  which  consists  of  round  and  oval  spores  which  stick 
to  each  other,  and  in  this  way  form  a  more  or  less  ramifying  series 
of  threads.  The  longer  the  sore  continues,  the  more  marked  is  its 
penetration  by  these  threads  or  spores.  This  new  organization,  or 
fungus,  can  never,  however,  originate  or  be  generated  by  the  oi'gan- 
ism  itself,  but  is  always  the  result  of  germs  coming  from  outside 
sources.  It  is  not  peculiar  to  a  particular  sore,  though  it  occurs  most 
frequently  on  those  of  a  certain  order.  Besides  the  two  constituent 
parts,  epithelial  scales  and  fungus,  there  appears  sometimes  a  third 
constituent,  in  the  form  of  granules  or  granulated  matter. 

"From  this,"  continues  Professor  Bamberger,  "we  see  that  aphthae 
cannot  be  counted  among  the  products  of  inflammational  and  exuda- 
tional  processes,  as  so  frequently  considered ;  the  microscope  has 
failed  to  discover  an  exudational  appearance;  also,  there  is  wanting 
the  anatomical  and  clinical  appearances  of  inflammation.  True,  it 
may  be  that  it  is  found  in  association  with  a  catarrh,  but  this  is  an 
accident,  just  as  one  may  not  say  that  the  diarrhoea  so  frequently 
found  in  connection  with  the  sore  in  the  infant  is  the  cause  of  the 
sore,  as  he  might  not  say  that  the  sore  is  the  cause  of  the  diarrhoea. 
There  is,  in  aphthae,  no  ulceration,  the  soormasse  being  capable  of 
being  peeled  from  the  surface." 

Professor  Dewees  thus  refers  to  the  aphthae  as  exhibited  in  the 
infant : 

"This  complaint  is  generally  called  the  baby's  sore-mouth:  it 
consists  of  a  greater  or  less  number  of  white  vesicles  on  the  inside 
of  the  mouth.  It  very  generally  begins  on  the  inner  part  of  the 
lower  lip,  or  corners  of  the  mouth,  and  much  resembles  a  small 
coagulum  of  milk.  Prom  this  point  it  sometimes  spreads  itself 
very  rapidly  over  the  inside  of  the  cheeks,  tongue,  and  gums ;  and, 
at  others,  it  will  appear  in  the  same  form,  and  at  the  same  time,  on 
several  portions  of  the  mouth  ;  as  inner  portions  of  the  cheeks,  etc. 
The  French,  especially  M.  Billard,  make  it  a  different  disease  from 
what  they  term  'muguet.'  But,  from  a  careful  examination  of  the 
two  diseases,  I  believe  them  to  be  the  same,  differing  only  in  in- 
tensity. I  think  we  have  not  the  disease  which  he  terms  '  muguet,' 
or  I  do  not  understand  his  description :  as  far  as  I  have  been  able 


THE  APHTHA.  g^^ 

to  compare  them,  they  are  identical.  The  difference  may  consist  in 
the  modification  which  a  hospital  may  give  it;  if  there  be  a  dif- 
ference, I  think  it  must  be  owing  to  this  cause.  When  this  efflores- 
cence is  extensive,  the  child  slavers  very  much,  and  is  frequently 
embarrassed  in  its  sucking;  it  cries,  and  evidently  betrays  that  it 
is  in  pain;  it  is  very  restless  and  very  thirsty,  as  it  evinces  by  its 
frequent  stirrings,  and  its  disposition  to  be  continued  at  the  breast 
The  eruption  in  its  mildest  form  is  very  white,  and  looks  as  if  a 
stratum  of  milky  coagulum  were  spread  over  the  mouth.  It  some- 
times confines  itself  to  the  center  of  the  cheeks,  at  others  to  the 
lower  lip,  or  one  side  of  the  tongue.  In  its  severer  forms  the  ap- 
pearance of  the  eruption  is  of  a  dark-brownish  color  or  extremely 
red,  owing,  most  probably,  to  minute  portions  of  blood ;  but  both 
are  evidently  grades  of  the  same  affection,  changed  either  by  mis- 
management, constitution,  or  the  force  of  the  remote  cause. 

"This  affection  is  thought  to  be  altogether  of  a  symptomatic 
kind— or  very  rarely  idiopathic.  It  is  almost  uniformly  preceded 
by  a  deranged  condition  of  the  stomach  and  alimentary  canal,  and 
always,  we  believe,  by  some  disturbances  of  the  stomach  itself.  The 
brain  always  shows  signs  of  participating  in  this  complaint,  as  there 
is  almost  always  an  unusual  inclination  to  sleep,  though  the  child  is 
frequently  disturbed  in  its  nap  by  some  internal  irritation,  perhaps 
of  the  bowels  themselves.  This  disposition  to  sleep  is  so  well  known 
to  nurses  that  they  will  frequently  tell  you  '  the  child  is  sleeping  for 
a  sore-mouth.'  The  bowels  are  often  teased  by  watery,  acrid  .stools, 
of  a  greenish  color  ;  their  discharge  is  frequently  attended  with  the 
eruption  of  much  wind,  and,  to  judge  from  the  noise,  it  would  be 
supposed  there  was  a  very  large  discharge  of  feces,  though,  upon 
examination,  it  is  found  to  be  very  sparing. 

"  The  alvine  discharges  are  frequently  very  acrid,  so  much  so, 
sometimes,  as  to  excoriate  the  verge  of  the  anus  and  nates  very 
severely;  especially  when  due  attention  is  not  paid  to  cleanliness 
or  to  the  frequent  changing  of  the  diapers.  But  this  never  takes 
place  until  the  disease  is  pretty  well  advanced,  and  has  made  some 
progress;  it  is  generally  pretty  well  spread  over  the  mouth,  and 
always  shows  a  violent  disease.  The  stomach  is  also  sometimes 
much  deranged  ;  vomiting  the  milk  very  soon  after  it  is  received 
into  the  stomach,  in  the  form  of  a  dense  curd,  mixed  Avith  a  porra- 
ceous  mucous  substance.  If  the  milk  be  not  voided  by  vomiting, 
the  stomach  constantly  discharges,  by  eructations,  a  gas  with  a 
very  sour  smell.     The  child,  when  the  disease  is  severe,  soon  be- 


608  ORAL  DISEASES  AND  SURGERY. 

comes  debilitated,  and  rapidly  emaciates ;  it  is  almost  constantly 
harassed  by  severe  colics  and  profuse  diarrhoea;  its  stomach  will 
scarcely  retain  the  little  it  can  swallow ;  and  the  oesophagus  some- 
times becomes  so  loaded  with  aphthae  that  it  can  no  longer  transmit 
the  small  quantity  which  is  reluctantly  admitted  into  the  mouth  ; 
and  the  child  dies,  either  from  the  exhaustion  consequent  upon  the 
profuseness  of  the  discharges  from  its  bowels,  or  from  inanition. 

"  It  is  a  popular  belief  that  this  aphthous  efflorescence  passes  from 
the  mouth  through  the  whole  tract  of  the  alimentary  canal  to  the 
very  termination  of  the  rectum  ;  and  the  excoriation  at  this  part  is 
offered  as  evidence  of  the  fact.  Whether  this  be  true  or  not  we  do 
not  know,  for  we  are  not  in  possession  of  any  facts  from  dissection 
which  decide  the  point.  We  once  examined  a  body  which  certainly 
died  from  aphthae,  the  examination  of  which  would  by  no  means  tend 
to  confirm  this  common  belief  A  child,  on  the  tenth  day  after  birth, 
was  observed  to  have  a  number  of  white  spots  upon  several  different 
portions  of  its  mouth,  which  rapidly  spread  over  its  whole  surface. 
It  had  the  usual  premonitory  and  accompanying  symptoms,  which 
increased  daily  in  severity,  in  spite  of  every  effort  to  oppose  them. 
It  was  a  feeble,  weakly  child,  of  a  consumptive,  feeble  mother.  Its 
sufferings  were  very  great,  though  under  some  control  from  lauda- 
num, so  long  as  it  could  be  taken  by  the  mouth,  or  retained  by  in- 
jections— coat  after  coat  of  aphthae  was  thrown  off,  and  each  new 
crop  appeared  to  be  more  abundant,  and  less  amenable  to  remedies, 
until  at  last,  at  the  end  of  two  weeks  of  severe  suffering,  the  poor 
infant  could  not  swallow  a  drop  of  the  thinnest  fluid.  Injections  of 
bark  and  mutton-tea,  in  conformity  with  popular  opinion,  were  re- 
sorted to,  but  all  in  vain ;  the  child,  in  a  few  days  more,  died  from 
absolute  starvation,  or,  at  least,  the  catastrophe  was  certainly  hur- 
ried by  the  impossibility  of  receiving  nourishment. 

"We  examined  the  body  after  death:  we  found  the  whole  tract  of 
the  oesophagus  literally  blocked  up  with  an  aphthous  incrustation, 
to  the  cardia,  and  there  it  suddenly  stopped.  The  inner  coat  of  the 
stomach  bore  some  marks  of  inflammation,  as  did  several  portions 
of  the  intestines ;  but  not  a  trace  of  aphthae  could  be  discovered 
below  the  place  just  mentioned.  This  case  would,  therefore,  create 
a  doubt  whether  this  affection  besieges  any  other  parts  of  the  body 
than  those  just  stated,  namely,  the  mouth,  posterior  fauces,  and  the 
oesophagus  to  the  cardia,  since,  perhaps,  none  could  have  been  of 
greater  severity  ;  but  it  is  with  us  a  solitary  case,  and  should  not  be 
received  for  too  much.     Dr.  Heberden  says,  '  The  aphthae  are  sup- 


THE  APHTHA.  q^^ 

posed  not  only  to  infest  the  mouth  and  fauces,  but  to  be  continued 
down  through  the  whole  intestinal  canal.  In  two  who  died  of  lin- 
gering fever,  and  whose  mouths  were  covered  with  aphtha;  which 
hung  in  rags  all  over  it,  there  was  not  the  least  trace  of  them  that 
could  be  found  in  dissection  beyond  the  fauces.'*  The  excoriations 
about  the  anus  can  certainly  be  accounted  for,  without  the  presence 
of  aphthae  to  produce  them;  in  bad  cases,  the  stools  are  always  ex- 
tremely acrid,  and  the  parts  over  which  they  constantly  pass  and 
spread  are,  at  such  a  tender  age,  very  delicate,  and  very  readily  ex- 
cited to  inflammation. 

"  Dr.  Good  seems  to  admit,  without  hesitation,  the  transmission 
of  aphthae  through  the  intestinal  canal ;  for  he  says,  without  reserve, 
'  The  fauces  become  next  affected,  and  it  descends  thence  through 
the  oesophagus  into  the  stomach,  and  travels  in  a  continuous  line 
through  the  entire  course  of  the  intestines  to  the  rectum,  the  feces 
being  often  loaded  with  aphthous  sloughs.'f 

"  We  are  afraid  there  is  too  much  taken  for  granted  in  this  ac- 
count; we  know  of  no  decided  evidence  of  the  fiict,  nor  does  Dr. 
Good  name  any  authority  for  the  statement.  The  case  alluded  to 
was  certainly  one  of  death  from  aphthae ;  but  in  it  the  aphthous 
efflorescence  stopped  at  the  cardia.  Is  it  probable  that  any  child 
could  survive  this  affection  did  it  travel  the  whole  course  of  the  in- 
testinal canal  ?  We  think  not — yet  aphthae  is  rarely  a  dangerous 
disease  in  infancy.  Dr.  Good's  description  of  this  affection  would 
certainly  lead  to  the  conclusion  that  it  is  the  ordinar}^  march  of  the 
disease  to  pass  through  the  bowels  and  manifest  itself  at  the  verge 
of  the  anus.  This  point  is  far  from  being  settled  in  the  minds  of 
pathologists:  even  the  French  are  far  from  having  ascertained  it 
with  certainty — it  is  true,  M.  Billard  says  he  has  seen  evidences  of 
it  in  the  large  and  small  intestines,  as  well  as  the  stomach  ;  but 
there  is  no  mention  of  it  lower  than  the  ileum. 

"Now,  this  cannot  be  so  ;  since  it  is  in  violent  and  long-protracted 
cases  alone  that  the  anus  discovers  any  signs  of  irritation  from  this 
cause,  which  would  not  be  the  case  were  Dr.  Good's  account  cor- 
rect. 

"Dr.  Good  and  others  suppose  that  aphthae  communicates  itself  by 

*  Commentaries,  p.  31.  "  It  is  well  known,  too,  that  in  small-pox  no  pus- 
tules are  traced  beyond  the  pharynx  and  larynx,  even  in  the  most  severe 
cases,  when  the  mouth  and  tongue  are  thickly  covered  with  the  eruption." — 
Tweedie's  Illustrations,  p.  65. 

t  Study  of  Medicine,  vol.  ii.  p.  391. 

39 


610  ORAL  DISEASES  AND  SURGERY. 

a  specific  contagion,*  and  gives  as  evidence,  the  excoriations  of  the 
nurse's  nipples.  We  do  not  hesitate  to  believe  there  is  a  discharge 
from  these  little  pustules  which  may  be  highly  acrimonious  to  the  de- 
nuded skin,  but  we  think  this  is  perfectly  innoxious  to  a  sound  one. 
For  we  have  never  seen  sore  nipples  produced  by  aphthae,  where  the 
skin  of  these  organs  was  perfectly  sound.  That  they  aggravate  the 
tenderness  and  inflammation,  when  these  parts  are  tender  and  abraded, 
we  admit,  and  so  would  any  other  acrid  substance,  without  having 
recourse  to  the  belief  of  a  specific  contagion.  If  this  were  the  case, 
why  do  not  the  lips  of  children  laboring  under  this  affection,  betray 
its  influence? 

"  That  this  complaint  is  occasionally  epidemic,  there  is  every  rea- 
son to  believe ;  and  this  circumstance,  among  some  others  to  be  men- 
tioned, renders  the  opinion  so  commonly  credited  (of  its  being  a  sym- 
pathetic affection),  very  questionable.  We  have  always  considered 
aphthae  as  arising  from  some  peculiar  condition  of  the  stomach  ;  but, 
from  some  late  cases,  and  more  mature  reflection,  we  think  it  maybe 
otherwise.     Our  reasons  for  doubt  are, — 

"  1.  We  have  recently  seen  this  affection  in  two  cases  where  the 
stomach  and  bowels  were  in  the  most  perfect  order  before  the  erup- 
tion, but  became  disturbed  a  little  during  the  progress  of  the  disease. 

"  2.  That  this  complaint  has  been  very  often  removed  by  topical 
applications  alone,  where  the  efiiorescence  has  been  very  consider- 
able, and  where  there  was  no  remedy  of  any  kind  addressed  to  the 
stomach  and  bowels. f 

"  3.  That  we  do  not  uniformly  see  this  complaint  where  there  has 
existed  great  disorder  of  both  stomach  and  bowels,  and  these  of  a 
permanent  kind. 

"  4.  That,  however  the  stomach  and  bowels  may  be  disturbed  by 
acidity  or  other  inconvenience,  or  however  long  these  may  continue, 
if  the  child  has  had  this  complaint,  it  is  not  renewed,  though  the 
individual  is  not  exempt  from  a  second  attack,  like  measles  or  small- 
pox; for,  in  certain  chronic  affections,  they  may  be  again  visited  by 
aphthae. 

"  5.  That  this  affection  is  sometimes  epidemic,  as  stated  above ; 
for  Dr.  Good  informs  us  that  not  only  all  the  children  of  the  same 
family,  however  cautiously  separated  from  one  another,  but  many  of 

*  M.  Billard  declares  it  not  to  be  contagious. 

f  Query. — Is  then  the  unconquerable  diarrhoea,  sometimes  present,  a  mere 
accident,  or  would  it  not  be  more  easy  to  account  for  it  by  the  presence  of 
aphthae? 


THE  APHTHA.  ^^^^ 

those  of  the  same  neighborhood,  have  been  known,  at  times,  to  suf- 
fer from  it  simultaneously.  (Yo\.  ii.  p.  391.) 

"  6.  That  this  disease  is  almost  always  ushered  in  by  some  cere- 
bral affection,  as  great  drowsiness  or  watchfulness;  the  first  is  by 
far  the  most  common. 

"7.  That  other  portions  of  mucous  membranes  are  liable  to  the 
same  kind  of  eruption,  without  the  condition  of  stomach  or  bowels 
being  instrumental  in  its  production ;  for  we  have  seen  it  most  plen- 
tiful within  the  labia  pudendi,  as  well  as  on  the  internal  face  of  the 
prepuce. 

"These  facts  have  made  us  lately  question  the  sympathetic  origin 
of  aphthae;  yet  we  admit  they  are  not  altogether  conclusive  in  our 
own  mind ;  but  we  thought  it  proper  to  suggest  the  possibility  of 
its  being  an  idiopathic  disease  of  the  mucous  membrane. 

"  This  aifection  is  not  confined  to  early  infancy  ;  it  shows  itself  in 
the  more  advanced  periods  of  childhood,  and  from  that  to  any  period 
of  human  life.  It  is  sure  to  attend  the  last  stages  of  almost  every 
long-protracted  disease,  especially  those  which  may  have  wasting 
discharges;  such  as  phthisis  pulmonalis,  dysentery,  or  diarrhoea; 
and  when  it  does  appear,  it  is  almost  sure  to  be  a  fatal  harbinger. 

"  This  disease  is  not  essentially  accompanied  with  fever ;  if  it  ac- 
company any  chance  affection  which  is  attended  by  fever,  we  do 
not  find  it  to  heighten  the  existing  one. 

"Weakly  children,  and  especially  those  born  before  their  full 
period,  are  more  obnoxious  to  this  complaint  than  the  robust  and 
those  who  have  tarried  to  their  full  time  in  the  uterus — the  children 
of  weakly  women,  and  particularly  those  who  make  bad  nurses  from 
scarcity  of  milk,  or  from  its  not  being  of  a  sufiBciently  nutritious  qual- 
ity, are  more  disposed  to  this  affection  than  the  children  of  hale 
women,  who  have  plenty  of  nourishment  of  good  quality.  The 
children  fed  much  upon  farinaceous  substances  are  especially  ex- 
posed to  the  attack  of  this  disease,  particularly  when  their  food  is 
sweetened  with  brown  sugar  or  molasses." 

In  the  work  by  M.  Jourdain  "  On  the  Surgical  Diseases  of  the 
Mouth "  is  a  chapter  on  aphthge,  so  unlike  all  that  precedes  it,  as 
connected  with  modern  pathology,  that  I  cannot  but  think  the  book 
owes  the  presence  of  the  chapter  to  the  translator  rather  than  to  the 
author. 

"  The  term  aphtha,"  says  this  work,  "  is  used  alike  by  ancients  and 
moderns,  but  in  quite  a  different  acceptation.  The  former  define 
aphthifi  as  superficial  malignant  ulcers,  attended  with  heat,  occur- 


612  ORAL  DISEASES  AND  SURGERY. 

ring  especially  in  infants,  and  not  confined  to  the  mucous  membrane 
of  the  mouth.  It  is  at  the  present  day  universally  applied  to  those 
whitish  pustules  which  appear  on  the  mucous  membrane  of  the 
mouth,  and  sometimes  of  the  adjoining  parts.  Inattention  to  this 
difference  has  led  many  to  apply  to  the  latter  disease  a  treatment 
based  upon  the  definition  of  the  ancients,  whereas  the  two  are  pal- 
pably different. 

"  AphthiB  have  been  regarded  as  ulcers  ;  but  ulceration  implies 
solution  of  continuity,  whereas  in  true  aphthae  there  is  no  erosion 
or  decrease  of  substance,  but,  on  the  contrary,  an  increase  ;  desqua- 
mation of  the  aphthous  crust  leaves  no  trace  of  cicatrization.  Theo- 
rists speak  of  white,  red,  and  black  aphthae,  according  to  the  nature 
of  the  generating  humor ;  but  during  a  long  practice  I  have  never 
seen  them  of  any  other  color  than  white,  whitish,  or,  especially  when 
of  an  unfavorable  character,  ash-colored. 

"They  commence  by  small  white  spots,  usually  on  the  uvula, 
thence  spreading,  sometimes  over  the  veil  of  the  palate,  sometimes 
over  the  tongue,  gums,  and  inside  of  the  lips  and  cheek.  Often  they 
spread  still  further  into  the  pharynx  and  oesophagus.  Of  their  ex- 
tension beyond  this  we  cannot,  of  course,  have  the  evidence  of  sight; 
but  we  have  other  and  unequivocal  symptoms,  which  prevent  us 
from  regarding  as  an  absurdity  the  idea  of  their  presence  in  the 
oesophagus,  stomach,  and  smaller  intestines ;  as,  for  instance,  in  the 
difficulty  of  breathing  and  deglutition;  also  in  the  appearance  of  the 
discharges  from  the  stomach  and  bowels,  so  frequent  in  aphthous 
disease. 

"  The  description  of  aphthae  is  easier  than  their  etiology.  We 
maintain  that  they  depend  in  all  cases  upon  the  same  cause,  differ- 
ing, indeed,  in  degree  of  intensity,  but  never  in  its  nature.  We 
therefore  differ  from  those  who  assign  one  cause  in  adults  and  an- 
other in  infants.  Nor  can  we  agree  with  the  many  who  make  them 
to  arise  from  excess  of  serum  or  of  acid  in  the  milk  or  nourishment 
given  to  the  infant.  The  depleting,  purging,  and  starving  treat- 
ment based  upon  this  hypothesis  is  most  pernicious  ;  moreover,  expe- 
rience tells  us  that  this  very  acidity  or  astringency  of  aliment  will 
frequently  cure  aphthous  eruptions,  or  prevent  them  from  coming  to 
maturity ;  and  a  serous  flux,  determining  to  the  mouth,  has  caused 
the  complete  disappearance  of  existing  aphthae. 

"  What,  then,  is  the  true  origin  of  this  disease  ?  We  believe  it 
to  be  found  in  the  existence  of  a  slow  and  imperfect  crisis,  and  to 
arise  from  a  sulphurous  humor  generated  in  the  larger  vessels,  and 


THE  APHTHM.  gjg 

determining  to  such  parts  as  are,  by  position  or  structure  nio.t 
impressible.  Observe  for  a  moment  the  circumstances  and  charac- 
ter of  aphthae.  In  all  fevers,  in  the  young  and  in  the  vigorous,  their 
appearance  is  ever  preceded  by  a  crisis  more  or  less  distinct,  and, 
according  to  the  violence  of  the  primary  disease,  marked  by  more  or 
less  severe  symptoms.  In  one  case  nature  struggles  successfully 
with  the  acrimonious  morbific  principle,  a  favorable  crisis  occurs, 
and  an  aphthous  eruption  brings  great  relief  to  the  patient;  in  an- 
other case  this  morbific  principle  is  too  abundant,  obstinate,  or  nialiir- 
nant,— no  crisis  occurs,— no  aphthte,— nature  succumbs,  and  the 
patient  dies.  Again,  we  have  aphthae  through  the  critical  transfer 
of  morbid  action  from  some  more  or  less  vital  and  important  organ. 
In  some  cases  the  change  proves  salutary ;  in  others  there  is  a  reac- 
tion, the  aphthae  disappear,  and  if  the  vis  vitse  be  not  destroyed,  it 
is  often  greatly  endangered. 

"  Aphthae  rarely  occur  in  a  perfect  and  favorable  crisis,  but  rather, 
as  we  have  before  said,  in  those  which  are  slow  and  imperfect,  such 
as  are  met  with  in  a  great  number  of  diseases.  Thus  we  find  some 
aphthous  eruptions  of  not  only  days',  but  weeks'  and  months'  contin- 
uance. When,  for  instance,  necessary  evacuations  have  been  neg- 
lected in  the  onset  of  disease,  and  a  cachectic  plethora  has  super- 
vened, the  cure  is  slow  and  incomplete  without  the  occurrence  of 
aphthae.  Diuretics  and  gentle  enemas  aid  the  recovery;  blood-let- 
ting and  purgatives  retard  it :  the  aphthee  disappear  after  fulfilling 
their  sanative  purpose,  and  the  patient  feels  perfectly  relieved.  Ex- 
perience, however,  shows  that  the  danger  is  not  quite  over ;  some 
lurking  matter  may  take  fresh  increase,  give  rise  to  new  aphthae,  in 
default  of  other  means  of  escape  from  the  system,  and  greatly  endan- 
ger life  ;  this  may  happen  twice,  thrice,  or  oftener. 

"  The  causes  or  antecedent  symptoms  of  aphthae  may  be  mild,  and 
recovery  take  place  without  any  or  with  very  simple  treatment ;  or 
they  may  be  severe  and  lamentable,  ending  in  suffocation,  delirium, 
or  obstinate  diarrhoea.  This  difference  we  find  explained  by  the 
varying  state  of  the  humors ;  at  one  time  being  crude,  and  by  con- 
sequence irritating,  at  another  time  matured  or  concocted,  by  which 
process  of  concoction  the  more  hurtful  principles  are  expelled, — a 
process  aided  in  some  inexplicable  manner  by  the  continued  circu- 
lation of  the  animal  spirits.  Thus  it  happens  that  the  aphthae  of 
seventh-day  crises  are  usually  more  unfavorable  than  those  which 
follow  crises  of  a  later  date,  when  the  morbid  matter  has  had  time 
to  undergo  a  thorough  concoction. 


614  ORAL  DISEASES  AND   SURGERY. 

"  Although  aphthae  are  most  generally  preceded  by  febrile  mias- 
mata, they  are  not  necessarily  so.  I  have  seen  cases,  both  among 
adults  and  infants,  in  which  they  have  been  neither  preceded  nor 
attended  by  fever.  In  infants  we  may  properly  suspect  impurity 
of  the  mother's  blood. 

"  Certain  evacuants  have  been  found  more  hurtful  than  beneficial 
in  the  treatment  of  aphthae.  This  comes  from  a  forgetfulness  of  the 
excellent  advice  of  Hippocrates,  who  tells  us  to  have  regard,  in  the 
choice  of  depleting  agents,  to  the  channels  of  evacuation  which  na- 
ture points  out  in  any  given  case.  Now,  the  vessels  concerned  in 
the  critical  discharge  of  an  aphthous  eruption  are  the  lymphatic 
rather  than  the  venous  or  arterial  vessels.  Therefore  to  the  changes 
of  the  lymphatic  fluid,  rather  than  to  those  of  the  blood,  is  our  atten- 
tion to  be  mainly  directed  in  the  management  of  this  disease.  We 
have  frequent  evidence  of  serous  or  lymphatic  engorgement  at  the 
outset  of  aphthous  eruptions ;  in  the  fever,  stupor,  and  restlessness 
during  sleep, — indicating  a  fullness  of  the  head  and  an  acrimony  of 
the  humors. 

"  Aphthae  are  more  common  in  some  countries  than  in  others, 
which  explains  the  almost  total  silence  of  some  writers  respecting 
them.  This  depends  upon  difference  in  climate  and  mode  of  living. 
In  warm  countries  their  course  is  rapid,  from  the  increased  perspira- 
tory action  of  the  skin.  But  in  colder  latitudes,  where  the  food  is 
coarser,  the  habit  of  body  denser,  and  the  humors  thicker,  their 
progress  is  slower,  because  the  secretions  of  the  system  generally 
are  more  liable  to  obstruction.  In  these  countries,  especially,  all 
discharges  which  tend  to  arrest  perspiration,  such  as  hemorrhoidal, 
intestinal,  or  uterine,  whether  occurring  spontaneously  or  artificially 
provoked,  are  very  unfavorable  in  the  treatment  of  aphthEe.  On  the 
contrary,  a  copious  cutaneous  or  urinary  secretion  forms  often  a  favor- 
able crisis.  This  agrees  with  the  doctrine  that  aphthae  are  essentially 
serous,  and  most  readily  cured  by  a  free  discharge  of  serum  or  lymph. 
The  cause  of  endemics  we  leave  others  to  explain ;  each  country 
bears  in  its  womb  the  seeds  of  its  own  diseases,  aud  also  the  means 
for  their  cure.  External  agencies  may  cause  aphthae,  not,  as  the  an- 
cients supposed,  by  their  direct  action  on  the  mouth,  but  indirectly, 
through  the  mass  of  the  circulating  fluids. 

"  The  diagnosis  of  aphthae  is  easy  ;  not  so  the  correct  interpreta- 
tion of  their  premonitory  symptoms.  Painful  deglutition,  dryness 
of  the  mouth,  a  thick,  husky  voice,  heat  of  the  stomach,  with  rum- 
bling noises,  disturbed,  unrefreshing  sleep, — these  often  precede  aph- 


THE  APHTHM.  gl5 

thous  eruptions.  Urinaiy  symptoms  are  not  to  be  relied  upon,  though 
often  useful  in  prognosis  after  the  appearance  of  the  eruption.  In 
the  different  forms  of  fever,  the  obstinacy  of  the  disease  is  often  a 
precursory  symptom;  when,  notwithstanding  the  intestinal,  uri- 
nary, and  other  evacuations,  there  still  exists  great  depression  and 
embarrassment  of  the  vital  functions,  the  appearance  of  aphtha  will 
often  in  a  single  night  bring  calm  and  relief  to  the  patient,  as  expe- 
rience has  abundantly  testified.  The  physician  should  follow  na- 
ture's hint,  and  seek  to  aid  in  the  cure  of  the  disease  through  the  same 
channels.  The  above  symptoms,  be  it  understood,  are  by  no  means 
necessarily  followed  by  aphthous  eruptions. 

"We  should  be  careful  in  our  prognosis :  where  the  system  is  not 
weakened,  the  pre-existing  morbid  matter  w^ell  concocted,  or  the 
extent  of  the  eruption  limited  to  the  palate,  we  may  anticipate  a 
favorable  issue.  But  if  the  patient  be  in  a  reduced  and  weakened 
condition,  the  morbid  matter  crude,  or  the  aphthae  covering  the  entire 
membrane  of  the  mouth  and  pharynx,  the  disease  is  much  more  to 
be  feared.  Again,  suppression  or  derangement  of  the  menstrual  flux 
is  unfavorable,  from  its  tendency  to  draw  the  eruption  from  the 
place  where  alone  it  can  properly  mature.  Profuse  alvine  or  hemor- 
rhoidal discharges  are  also  hurtful;  also  any  catai-rhal  attack  falling 
upon  the  throat,  causing  the  sudden  disappearance  of  the  aphthae. 
Aphtbse  occurring  in  diseases,  at  the  onset  of  which  there  was  in- 
sufficient evacuation,  are  grave  and  dangerous.  The  disease  may 
occur  in  persons  of  either  sex,  and  be  of  tedious  duration;  but  when 
the  appetite  returns,  not  only  is  the  food  highly  relished,  but  it  gives, 
by  its  new  nourishment,  relief  and  salutary  benefit." 

"  The^term  aphthae,"  says  Prof  Wood,  in  his  Practice  of  Medicine, 
vol.  i.  page  501,  "was  employed  by  the  ancients  to  signify  various 
inflammatory  affections  of  the  mucous  membrane  of  the  mouth. 
Willan  proposed  to  restrict  it  to  a  peculiar  vesicular  eruption  upon 
the  membrane,  but  committed  the  error  of  confounding  with  this 
affection  the  thrush  of  early  infancy.  The  two  complaints  are  quite 
distinct,  and  should  not  be  similarly  designated.  Aphthas,  in  com- 
pliance with  very  general  custom,  is  extended  to  all  those  small 
ulcers,  with  whitish  surface,  which  so  frequently  appear  in  the 
mouth,  whatever  may  be  their  origin.  The  most  frequent  source  of 
aphtha;  is  probably  the  vesicular  eruption  occasionally  present  in 
erythema.  The  vesicle  is  small,  oval,  or  roundish,  white  or  pearl- 
colored,  and  consists  of  a  transparent  serous  fluid  under  the  elevated 
epithelium.  In  a  few  days  the  epithelium  breaks,  the  serum  escapes, 


616  ORAL   DISEASES  AND   SURGERY. 

and  a  small  ulcer  forms,  more  or  less  painful,  with  a  whitish  bottom, 
and  usually  a  red  circle  of  inflammation  around  it.  The  vesicles  are 
sometimes  distinct  and  scattered,  sometimes  numerous  and  confluent. 
The  distinct  variety,  though  painful,  is  a  light  affection,  continuing 
in  general  only  a  few  days  or  a  week,  and  is  usually  confined  to  the 
mouth.  It  produces  little  or  no  constitutional  disorder,  though  it 
may  be  associated  with  fever  and  gastric  irritation  as  an  effect.  It 
attacks  equally  children  and  adults,  but  is  said  to  be  very  common 
in  early  infancy.  In  adults  it  is  frequently  occasioned  by  the  irrita- 
tion of  decayed  teeth.  The  confluent  variety  is  much  more  severe 
and  obstinate.  This  frequently  extends  into  the  fauces  and  pharynx, 
and  is  said  to  reach  even  the  intestinal  canal,  though  it  may  be 
doubted  whether  the  affection  of  the  stomach  and  bowels  is  identical 
with  that  of  the  mouth." 

The  French  fail  in  distinguishing,  with  Prof  Wood,  the  difference 
between  the  pultaceous  inflammation  of  thrush,  or  muguet,  and  the 
aphthae,  calling  muguet  the  "  aphthes  des  enfans."  They  recognize 
also  that  there  are  variations  in  the  expressions  of  the  condition, 
making  a  distinction  between  the  viuguet  henin  ou  discret,  and  the 
confluent,  muguet  malin  ou  confluent. 

In  Clymer's  Aitken's  Science  and  Practice  of  Medicine,  the  subject 
is  thus  alluded  to:  "Follicular  inflammation  of  the  mouth,  follicular 
stomatitis,  aphthous  stomatitis,  or  aphthae  of  the  mouth,  is  a  disease 
which  usually  commences  as  a  simple  stomatitis ;  but  very  soon 
small,  round,  transparent,  grayish  or  white  vesicles  appear,  and  at 
the  base  of  each  is  an  elevated  marginal  ring,  which  is  pale  and 
firm.  Fluid  soon  escapes  from  the  ruptured  vesicle ;  an  ulcer 
forms,  which  spreads,  bounded  by  a  red  circle  and  an  elevated 
border.  In  some  forms  of  the  affection  microscopical  parasitic 
plants  appear." 

Treatment. — If  we  are  content  to  view  aphthae  simply  as  a  fun- 
gous sore,  originating  from  and  maintained  by  the  presence  of  a 
parasite, — the  oidium  albicans, — we  would  find  a  most  admirable 
application  in  carbolic  acid,  admitting  that  the  parasite  had  an  ex- 
ternal relation  only;  if,  however,  these  spores  come  from  within 
and  are  exudational,  such  local  treatment  would  stand  us  alone  to  a 
very  temporary  end. 

Viewing  the  fungus  simply  as  an  accidental  parasite  external  in  its 
relations,  our  attention  is  directed  primarily  to  the  necessity  for 
cleanliness,  and  the  avoidance  of  all  positions,  locations,  and  circum- 
stances favoring  the  development  of  fungi;  carbolic  acid,  acid  nitrate 


THE  APHTHA. 


617 


of  mercury,  sulphuric  acid,  nitrate  of  silver,  or  chloride  of  zinc,  will 
be  found  destructive  to  the  parasite,  and,  of  necessity,  if  the  circum- 
stances are  changed,  equal  to  the  production  of  a  permanent  change 
in  the  appearance  of  the  part ;  that  is  to  say,  the  application  is  equal 
to  the  removal  of  the  envelope  or  cover  of  the  disease,  but,  except  bv 
a  happy  accident,  will  not  beneficially  affect  the  underlying  condition 
or  the  disease  proper. 

In  the  treatment  of  aphthae,  the  practitioner  finds  himself  com- 
pelled, at  the  very  outstart,  to  consider  the  constitutional  associa- 
tions. Occurring  in  connection  with  acute  diseases,  it  is  generally 
the  case  that  the  local  expression  is  found  to  disappear  with  the 
condition  exciting  it.  Thus,  in  febrile  attacks  attended  with  stoma- 
titis, we  direct  our  remedies  to  the  causes  inducing  such  attacks ; 
as  the  functions  become  harmonized  and  regulated,  the  expressions 
of  the  irregularity  disappear. 

Aphthae,  whatever  its  form,  appearing  in  connection  with  the 
dyscrasic  diseases,  gives  to  the  practitioner  the  greatest  anxiety  and 
trouble.  In  our  anticipations  of  what  we  are  to  do,  we  are  not  to 
forget  that  the  task  before  us  is  the  removal,  or,  at  least,  the  marked 
amelioration,  of  the  constitutional  disease.  If  this  should  be  syphi- 
litic, tubercular,  or  cancerous,  the  magnitude  of  the  task  is  evident : 
hence  it  is  that  patients  are  allowed  so  frequently  and  so  unneces- 
sarily to  find  themselves  subjected  to  a  series  of  disappointments. 

Acute  aphthae,  as  manifested  in  cancrum  oris,  gangraena  oris,  and 
follicular  inflammation,  demands  not  unfrequently  the  most  attentive 
local  treatment.  This  treatment  has,  however,  nothing  particularly 
special  in  it,  and,  without  doubt,  must  be  appreciated  from  the 
general  expressions  of  the  subject.  Alteratives  and  soothing  ap- 
plications are  such  as  would  naturally  commend  themselves.  Sul- 
phate of  copper,  in  proportions  varying  from  five  to  thirty  grains  to 
the  ounce  of  water,  is  an  excellent  application.  Iron  and  quinine 
in  combination  is  used  to  great  advantage,  twenty-five  grains  of  the 
latter  to  one  drachm  of  the  muriated  tincture.  A  powder  made  by 
combining  equal  parts  of  red  bark,  chalk,  and  tannic  acid  is  fre- 
quently found  very  serviceable.  Solutions  of  alum,  and  the  tinctures 
of  capsicum  and  myrrh,  are  useful  in  their  places ;  also  borax,  oxalate 
of  cerium,  powdered  chlorate  of  potash,  sulphate  of  iron,  etc. 

Where  the  parts  seem  angry  and  irritable,  or  phagedenic,  com- 
bined with  these  applications  are  to  be  employed  the  more  soothing 
means :  starch,  gum,  and  slippery-elm  water  are  very  serviceable. 
Tincture  of  hamamelis,  much  diluted,  is  a  good  preparation.     It  is 


618  ORAL  DISEASES  AND  SURGERY. 

to  be  understood  that  while  the  principles  which  govern  the  treat- 
ment of  the  aphthae  are  common  to  the  species,  the  applications 
must  vary  to  meet  peculiar  indications.  The  ordinary  white  sores, 
for  example,  need  little  more  in  the  way  of  a  local  treatment  than 
the  continued  application  to  them  of  some  of  the  agents  mentioned : 
which  one  would  be  best,  or,  indeed,  what  would  be  best,  we  could 
not  well  say,  unless  considering  a  particular  case.  The  local  treat- 
ment is  not,  however,  in  any  of  these  cases  urgent,  and  it  is  the 
general  experience  that  we  find  ourselves  trying  first  one  thing 
and  then  another ;  indeed,  it  is  unfortunately  too  common  that  we 
are  soon  brought  to  the  conviction  that  any  local  application  is 
unreliable  enough, — not  that  we  cannot  cause  a  sore  to  disappear, 
but  that  to-day,  to-morrow,  or  next  week,  another  comes  to  take  its 
place.  Canker  sores  seem  periodic  in  some  persons ;  they  come 
without  perceptible  cause  other  than  what  seems  a  persistent  con- 
stitutional condition,  defy  all  treatment,  and  finally  disappear  of  their 
own  accord. 

Of  the  special  conditions,  thrush  demands  that  the  bowels  should 
be  kept  free  from  costiveness, — oil,  the  saline  cathartics,  or  aloes 
being  employed  as  indicated.  Where  fever  attends  the  local  mani- 
festation, it  is  well  to  prescribe  the  neutral  mixture  made  by  fully 
saturating  lemon-juice  with  the  carbonate  of  potassa;  or,  if  more 
agreeable  to  the  patient,  the  ordinary  lemonade  may  be  used.  In 
diarrhoea,  which  is  so  frequent  an  attendant  on  thrush,  some  such 
combination  as  the  following  may  be  used  : 

B. — Hydrarg.  chl.  mit.  gr.  ij  ; 

Pulv.  opii, 

Pulv.  ipecac,  aa  gr.  i ; 

Mag.  carb.  gr.  xii.     M. 
Ft.  chart.  No.  xii. 

Of  these  powders,  the  infant  may  take  one,  mixed  in  molasses  or 
other  vehicle,  every  two  hours,  until  the  discharge  is  checked  or 
until  the  twelve  are  taken.  In  diarrhoea  with  green  discharges  it 
may  be  sufficient  to  use  the  magnesia  alone,  or  lime-water,  which  is 
more  convenient  of  exhibition,  may  suffice  for  the  correction  of  the 
acidity :  this  latter  can  be  rendered  palatable  by  combination  with 
some  of  the  aromatic  waters.  In  cases  associated  with  much  in- 
testinal disturbance,  it  will  in  most  instances  be  found  satisfac- 
tory practice  to  combine  laudanum  or  paregoric  with  olive  or  cas- 


THE  APHTHM. 


619 


tor  oil,  administering  in  such  doses  as  accords  with  the  age  of  the 
patient.  A  child  one  year  of  age  may  take  three  drops  of  lau- 
danum or  twenty  of  paregoric,  combined  with  a  teaspoonful  of 
the  oil ;  for  an  adult  a  dose  would  be  twenty-five  or  thirty  drops 
of  laudanum  to  a  tablespoonful  of  the  oil.  It  is  also  found  use- 
ful to  drink  freely  of  the  demulcent  waters,  marshmallow  and  gum 
arable  being  among  the  best  of  these.  In  debility— and  this  is  by 
far  the  most  frequent  of  the  conditions — combinations  of  iron  and 
bark,  conjoined  with  the  most  nutritious  articles  of  diet,  will  be 
found  indicated :  ferrated  elixir  of  cinchona  is  a  pleasant  and  very 
reliable  preparation,  and  is  freely  taken  by  children.  The  dose  far 
an  adult  is  one  teaspoonful,  repeated  three  or  four  times  a  day ;  to 
an  infant  a  year  old,  ten  drops  may  be  given. 

Concerning  the  diet,  if  the  patient  is  beyond  the  age  of  infancy,  it 
will  be  found  that  the  richest  food  is  most  advantageously  received ; 
juicy  beef,  oysters,  malt  liquor,  wine,  etc.  being  freely  allowed.  In 
the  infant,  the  character  of  the  milk  of  the  mother  is  to  be  examined: 
in  many  cases  it  will  be  found  needful  to  furnish  a  different  nurse, 
or,  otherwise,  wean  the  child.  Many  cases  of  persistent  thrush  in  the 
infant  have  quickly  disappeared  after  a  change  of  nurses. 

Gangraena  oris,  the  most  degenerative  and  destructive  of  the  aph- 
thae, requires  the  most  persistent  vigor  in  the  treatment,  both  as 
regards  systemic  and  local  conditions.  Sulphate  of  quinia  and  the 
muriated  tincture  of  iron  are,  in  the  first  direction,  most  to  be  relied 
on.  This  condition  occurs  most  frequently  between  the  periods  of 
1  first  and  second  dentition,  and  is,  without  doubt,  more  common  to 
I  the  miasmatic  than  to  other  regions,  excepting  always  the  location 
of  ill-kept  and  ill-ventilated  charities.  Gangraena  oris  may  have  a 
local  excitant,  but  it  is  never  without  a  constitutional  predisposition : 
it  may  commence  as  a  simple  sore,  gradually  degenerating,  or,  as  in 
carbuncle,  destruction  may  reside  in  the  primary  impression.  A 
common  form  of  sloughing  stomatitis  is  its  appearance  as  a  whitish 
or  ash-colored  eschar  situated  upon  the  gums,  lips,  or  cheeks.  This 
eschar  quickly  falls  out,  being  followed  by  degeneration  of  the  asso- 
ciate parts;  the  breath  becomes  offensive,  the  saliva  flows  as  in 
ptyalism,  while,  to  add  to  the  discomfort,  the  ulcer  pours  out  an 
acrid,  corrosive  fluid,  which  not  only  excoriates  the  mouth,  but 
seems  to  provoke  the  extension  of  the  mortification.  If  not  checked, 
the  ulceration  extends  to  the  bone,  quickly  involving  it  in  the  gen- 
eral destruction,  and  bringing  on  the  condition  of  necrosis,— necrosis 


620  ORAL  DISEASES  AND   SURGERY. 

infantilis,  as  the  disease  is,  unfortunately,  so  frequently  compelled 
to  be  named. 

The  treatment  of  gangraena  oris  is  precisely  that  of  a  carbuncle. 
We  endeavor  to  circumscribe  the  action  by  sloughing  out  the  af- 
fected part  with  the  aid  of  caustic ;  this  accomplished,  we  stimulate 
the  general  system,  correct,  where  possible,  all  functional  disturb- 
ances, and  use  for  the  relief  of  the  local  sore  such  soothing  means 
as  seem  indicated. 


CHAPTER    XXXIX. 

RANULA. 

The  subject  of  ranula  is  one  easily  compreliended.  A  ranula  is 
the  analogue  of  the  sebaceous  tumor,  being  simply  a  collection,  the 
result  of  the  closure  of  a  tube  of  outlet.  The  tumor  thus  designated 
is  found  principally  beneath  the  tongue:  it  is  generally  a  translucent 
swelling,  varying  in  size  according  to  the  length  of  time  it  has 
existed,  at  times  being  observed  when  not  larger  than  a  pea,  at 
others  so  great  in  bulk  as  to  throw  the  tongue  back  into  the  fauces. 
I  have  seen  a  ranula  which  filled  the  whole  oral  cavity ;  but  such 
dimensions  are  uncommon. 

Recalling  the  anatomy  of  the  salivary  glands,  we  remember  that 
the  submaxillary,  situated  beneath  the  jaw,  has  the  outlet  for  its 
secretions  in  a  tube  opening  at  the  side  of  the  fraenum  lingure, — the 
duct  of  Wharton,  as  it  is  called.  The  lingual  gland  empties  itself  on 
the  same  line.  The  parotid,  by  its  tube,  the  duet  of  Steno,  opens 
upon  the  mucous  face  of  the  cheek  opposite  the  superior  second 
molar  tooth.  While  patulous,  these  tubes  convey  into  the  mouth 
the  secretions  of  their  respective  glands,  and  thus  the  saliva,  passing 
'to  its  recremental  purpose,  is  disposed  of 

If  we  were  to  tie  or  otherwise  obstruct  one  of  these  tubes,  it 
would  be  natural  to  expect  that  the  secretion  accumulating  back  of 
the  ligature  would  expand  and  bulge  out  the  duct  into  the  form 
of  a  tumor.  This  is  the  very  simple  history  of  the  formation  of  a 
ranula. 

Ranula,  thus  provoked  and  thus  formed,  varies  much  in  appearance 
and  character.  In  one  case  it  will  look  and  feel  almost  precisely  like 
the  belly  of  the  frog,  the  enveloping  cyst  being  thin  and  attenuated. 
In  another  instance  the  walls  are  thick.  The  contents  present  vary- 
ing characteristics,  being  watery,  or  semi-solid,  or  solid,  even  to 
the  hardness  of  stone,  as  illustrated  in  the  very  instructive  case  cited 
in  the  chapter  on  Salivary  Calculus. 

]     A  ranula,  the  contents  of  which  are  waterv,  implies,  as  a  rule,  that 
I  (  621  ) 


622  ORAL  DISEASES  AND   SURGERY. 

the  disease  has  been  of  short  existence,  the  contents  being  simply 
the  secretion  from  the  gland  unchanged  in  character.  In  the  ranula 
of  semi-solid  consistence  an  explanation  is  found  in  the  partial 
absorption  of  the  more  fluid  portion,  leaving  an  inspissated  mass. 
In  the  solid  ranula  the  encystment  is  the  common  salivary  calculus, 
— precisely  the  same  as  is  found  upon  the  sides  of  the  teeth,  ex- 
cepting in  the  absence  of  the  common  debris  of  the  mouth.  Such  a 
ranula  Avill  be  found  to  be  of  long  standing:  absorption  of  the 
watery  portion  has  gone  on  until  what  remains  is  the  lining  portion 
of  the  secretion. 

A  thin  cyst  implies  a  rapidly-formed  tumor  unattended  by  vas- 
cular excitement,  the  envelope  being  a  simple  attenuation  of  the 
walls  of  the  duct  and  overlying  parts.  This  form  of  ranula  very 
frequently  ruptures  and  thus  effects  a  self-cure.  Cysts,  thickened 
and  hard,  imply  a  tumor  of  slower  growth  and  the  association  of 
vascular  changes  resulting  in  the  effusion  within  the  cyst-wall,  and 
the  organization  of  a  greater  or  less  amount  of  lymph.  Cysts  thus 
thickened  may  compose  the  principal  bulk  of  a  ranula,  the  cavity 
being  very  small  in  comparison. 

A  ranula  gives  trouble  from  its  bulk  and  location  alone,  seldom  or 
never  degenerating.  It  does  not  seem  true,  either,  that  harm  results 
to  digestion  from  the  loss  of  the  secretion,  such  loss,  indeed,  being 
more  apparent  than  real,  the  associate  glands  performing  excess  of 
work.  A  ranula  attaining  great  size  would  necessarily  intrude  upon 
all  the  surrounding  parts,  thereby  provoking  secondary  lesions  which 
might  very  well  prove  of  more  serious  character  and  consequence 
than  the  original  disease :  thus,  cases  are  on  record  where  the  teeth 
have  been  forced  from  their  sockets,  where  large  ulcers  have  been  j 
formed  against  the  inner  face  of  the  lower  jaw,  where  necrosis  of  ex- ; 
tensive  character  has  been  provoked,  etc. 

Treatment. — This,  in  principle,  consists  simply  in  opening  the 
tumor,  evacuating  its  contents,  and  so  conducting  the  cure  of  the 
wound  that  it  shall  not  entirely  close,  securing  and  preserving,  in  ' 
this  way,  an  orifice  of  exit  for  the  secretion. 

In  the  rana,  or  frog-belly  tumors,  it  is  found  sufficient  to  catch  up 
with  the  tenaculum  or  forceps  a  portion  of  the  sac,  and  with  the  i 
scissors  or  bistoury  cut  it  off:  the  edges  are  then  to  be  cauterized,  j 
and  the  case  left  to  nature.  I 

In  the  thickened  cysts,  such  an  operation  as  just  suggested  might  '■ 
not  be  easy  to  accomplish.  In  such  a  case,  take  a  strand  of  ligature  '. 
wire  (silver  is  to  be  preferred),  double  it  upon  itself  some  half-dozen  i 


RANULA.  g23 

times,  to  the  extent  of  the  supposed  thickness  of  the  sac  of  the  tumor 
to  be  operated  upon.  Take  next  the  continuation  of  the  length  of 
the  wire,  and  closely,  yet  spirally,  bind  with  it  the  thickness  just 
secured  by  the  half-dozen  reflections.  Next  take  a  curved  needle, 
and  thread  the  wire  to  it.  Now  pass  it  through  the  tumor,  entering 
at  the  center.  When  the  thickened  part  of  the  wire— which  is  to 
be  bulbed  by  a  perforated  shot  compressed  on  its  extremity— is 
brought  in  contact  with  the  cyst,  it  is  to  be  let  in  by  an  incision 
just  large  enough  to  allow  the  passage  ;  pull  it  now  in,  until  checked 
by  the  shot ;  fix  the  needle-end  so  as  to  retain  the  thickened  end 
in  place,  and  the  operative  part  of  the  proceeding  is  completed. 

If,  when  making  the  little  section  for  the  passage  of  the  wire,  the 
contents  should  not  at  once  escape,  they  are  to  be  pressed  or  syringed 
out.  If  the  parts  seem  particularly  indolent,  there  is  no  objection 
to  the  introduction  of  a  stimulating  injection.  The  presence  of  the 
wire  will,  however,  in  ordinary  cases  prove  sufiBciently  provocative 
of  the  desired  action.  Iodine  in  tincture  may  be  used  externally 
over  the  face  of  the  tumor.  As  the  size  of  the  tumefaction  gradually 
diminishes,  the  thickened  end  of  the  seton  is  to  be  kept  in  place  by 
attention  to  the  fixing,  or  single-strand,  end. 

In  a  ranula  holding  a  calculus  within  the  cyst,  nothing  is  to  be 
done  without  using  the  knife,  except,  indeed,  in  certain  occasional 
cases  where  the  orifice  of  the  duct  has  become  patulous  and  the 
stone  can  be  seen  or  felt.  In  these  cases  the  operator  may  succeed 
in  drilling  or  breaking  them  in  pieces,  and  thus  securing  their  re- 
moval. It  is  much  easier,  however,  even  here,  to  incise  down  to 
the  stone,  and  thus  take  it  away.  The  case  alluded  to  as  mentioned 
in  the  chapter  on  Salivary  Calculus  is  as  good  a  study  as  could  be 

.  given  in  the  direction. 

All  cysts  or  tumors  found  beneath  the  tongue  are  not,  however, 
to  be  esteemed  as  being  of  the  character  just  described.  Inflamma- 
tion of  the  sublingual  gland  is  not  unfrequently  met  with,  and  the 
tumefaction  is,  at  times,  so  considerable  as  to  very  closely  simulate 
ranula.     Cysts  within  the  substance  of  the  glands,  not  salivary  in 

[■character,   are   other  of  the  conditions  met  with,  and  these  more 
closely  simulate   the  ordinary  ranula  than  the  first ;  particularly 

j'when  the  cyst  is  simple.     Papillary  indurations  are  sometimes  met 

i»with  in  the  same  situation. 

i     A  singular  case  operated  upon  by  myself,  and  where  I  very  nearly 

j  lost  the  patient,  occurred  in  the  person  of  a  confectioner,  and  has  the 

[following  history: 


624  ORAL  DISEASES  AND  SURGERY. 

First  it  was  noticed  that  the  parts  beneath  the  chin  began  to 
soften  and  grow  broad,  freedom  of  motion  was  lost  in  the  jaw, 
and  a  slight  sense  of  difficulty  was  experienced  in  speech,  as  the 
result  of  stiffness  about  the  tongue,  the  mucous  floor  of  the  mouth 
being  quite  indurated.  In  the  course  of  four  months  a  tumor,  evi- 
dently cystic,  and  fully  the  size  of  an  ordinary  orange,  occupied  the 
front  of  the  neck,  but  happily  concealed  by  the  long  and  heavy  beard 
of  the  patient. 

Presenting  himself  for  an  operation,  a  diagnosis  was  secured 
through  the  aid  of  an  exploring  needle.  This  valuable  instrument 
revealed  not  only  that  the  tumefaction  was  a  cyst,  but  gave  some 
idea  of  its  contents. 

The  operation  for  the  cure  was  performed  by  making  a  reasonable 
incision  directly  in  the  median  line  of  the  neck,  passing  into  the 
cyst.  The  contents,  a  great  mass  of  lymph-like  matter,  filling  a  large 
glass,  issued  as  a  continuous  rope;  in  color  and  consistence  it  was 
like  thin  calves'-foot  jelly.  Washing  the  cavity  thoroughly  with 
warm  alum-water,  compresses  were  carefully  adjusted  to  the  parts 
and  sustained  by  a  bandage  passing  over  the  forehead.  In  two 
weeks,  and  without  any  trouble,  the  parts  seemed  to  have  united, 
and  the  cyst  to  be  obliterated. 

One  month  later  the  patient  again  presented  himself.  The  tumor 
was  rapidly  reforming:  the  cyst  had  evidently  not  been  destroyed. 
It  was  now  the  size  of  a  walnut.  A  few  days  later  a  second  opera- 
tion was  performed,  precisely  as  in  the  first  instance.  The  contents 
of  the  tumor  differed,  however,  at  least  in  color,  having  the  same 
colloid  consistence,  but  being  blood-red.  After  an  incision,  deter- 
mined on  obliterating  the  cavity,  I  syringed  it  with  the  officinal  tinc- 
ture of  iodine,  undiluted,  stuffing  the  cyst  loosely  with  cotton.  I  this 
time  succeeded  in  producing  a  perfect  cure  ;  but  the  swelling  result- 
ing from  the  inflammation  was  so  great  that  it  was  only  by  leeches, 
cathartics,  and  diaphoretics,  conjoined  with  the  closest  attention, 
extending  over  a  period  of  four  days,  that  I  succeeded  in  saving  the 
life, — for  two  whole  days  the  patient  being  unable  to  swallow  even 
teaspoonful  measures  of  water,  and  breathing  with  the  greatest 
difficulty. 

What  was  this  tumor?  Evidently  a  hydro-hem atocele,  the  start- 
ing-point of  the  lesion  being,  I  think,  in  a  sublingual  gland.  It  might 
be  suggested  that,  had  it  belonged  to  this  gland,  the  swelling  would 
have  exhibited  itself  more  in  the  mouth.  My  reason  for  inferring  that 
it  was  so  situated  lay  in  the  fact  that  a  blunt  probe  passed  into  the 


BANULA.  g25 

cavity  could  readily  be  felt  in  the  position  of  the  ri^irht  of  these 
bodies  on  the  floor  of  the  mouth. 

A  case  very  similar  to  this,  and  of  great  interest,  is  recorded  in 
Bell's  Principles  of  Surgery  : 

"A  young  woman  of  Berwick  whose  native  peculiarity  of  accent 
had  received  a  singular  aggravation  by  such  an  uncouth  obliquity 
and  imperfect  motion  of  the  tongue  as  conveyed  the  notion  of  her 
attempting  to  chew  and  turn  each  vocable  with  her  tongue  before 
she  proceeded  to  swallow  it,  in  place  of  uttering  it. 

"  This  was  produced  by  a  tumor  of  very  great  size,  and  of  an 
appearance  so  peculiar  as  plainly  to  denote  its  character.     It  con- 
sisted in  a  vast  collection  of  matter  in  the  sublingual  gland;  and  as 
that  gland  is  covered  by  the  whole  thickness  of  the  tongue  within, 
and  by  the  mylo-hyoidei  muscles  without,  and  bounded  by  the  line 
of  the  jaw-bone,  it  had  the  following  singularities  of  character.     It 
could  not  be  distinguished  as  a  tumor,  but  had  rather  the  appear- 
ance of  a  general  swelling  of  the  lower  part  of  the  face,  jaw,  and 
neck,  such  as  often  accompanies  severe  toothache  or  mumps.    Upon 
laying  the  hand  upon  the  outside  of  the  neck,  below  the  lower  jaw- 
bone, the  whole  hand  was  filled  with  a  swelling,  apparently  solid, 
but  so  little  convex  or  circumscribed  as  to  resemble  in  no  degree  the 
tumor  of  any  particular  gland,  and  yet  so  limited  and  so  firm  as  not 
at  all  to  resemble  the  general  tumefaction  proceeding  from  tooth- 
ache.    Upon  introducing  the  finger  into  the  mouth,  you  found  the 
tongue  raised,  turned  edge  uppermost,  and  pressed  entirely  toward 
the  left  side  of  the  mouth,  the  external  tumor  being  upon  the  right 
side.     Upon  pressing  the  fingers  very  firmly  down  by  the  side  of 
the  tongue,  and  reaching  from  without,  you  could  sensibly  perceive 
not  so  properly  a  fluctuation  as  an  elasticity,  which  implied  the 
presence  of  a  fluid ;  the  tumor  seemed  elastic  like  a  foot-ball,  but 
with  a  degree  of  tension  which  made  it  seem  almost  solid.     It  was 
by  comparing  a  variety  of  circumstances,  especially  the  original 
place  and  slow  growth  of  the  tumor,  that  I  confidently  referred  it  to 
the  sublingual  gland.     In  this  I  had  the  advantage  of  the  surgeon 
under  whose  particular  care  she  was  ;  but  I  did  him  the  justice  to 
send  her  back  to  him,  again  and  again,  expressing  my  opinion  and 
my  wish,  at  the  same  time,  that  he  should  do  whatever  he  might 
suppose  right.     By  good  fortune,  she  called  upon  me  the  day  she 
was  to  return  home,  nothing  being  as  yet  done  to  the  tumor,  but 
supplied  with  abundance  of  blisters  and  plasters  to  apply  at  a  fit 

40 


626  ORAL  DISEASES  AND  SURGERY. 

opportunity  to  her  throat.  I  felt  now  that  professional  ceremonies 
should  give  way  to  essential  charities.  I  placed  her  in  a  chair,  and 
almost  without  her  consciousness,  at  least  before  she  was  aware,  I 
struck  a  fine  bleeding-lancet  deep  into  the  tumor  by  the  side  of  the 
fraenum  of  the  tongue,  when,  from  the  firm  compression  of  the  sur- 
rounding parts,  the  matter,  though  too  gross  to  pass  freely  through 
such  an  opening,  was  spewed  out  from  the  orifice,  in  a  manner  ex- 
pressly resembling  that  in  which  yellow  paint  is  squeezed  out  from 
the  bladder  upon  a  painter's  pallet.  It  was  of  a  deep-saffron  color, 
thicker  than  mustard,  mixed  like  gruel  with  seed-like  particles,  and 
exceedingly  fetid.  I  knew  that  the  tumor  was  not  emptied,  though 
the  outward  swelling  was  almost  gone ;  but  I  also  knew  that  though 
I  should  not  enlarge  the  opening,  the  second  secretion  from  the  sur- 
face of  the  sac,  which  is  in  all  cases  thin,  would  dilute  and  wash  out 
whatever  viscid  matter  remained ;  and  when  she  saw  how  suddenly 
my  prognostic  was  fulfilled,  she  expressed  a  perfect  confidence  in 
whatever  I  predicted,  and  a  perfect  willingness  to  submit  cheerfully 
to  whatever  I  proposed  to  do.  Next  day  I  introduced  the  point  of 
a  probe-pointed  bistoury  into  the  orifice  made  by  the  lancet ;  and, 
knowing  that  the  lingual  artery  lies  on  a  lower  level,  imbedded 
among  the  muscles,  and  running  along  the  lower  surface  of  the 
tumor,  while  I  had  over  the  point  and  blade  of  my  bistoury  nothing 
but  the  inside  membrane  of  the  mouth,  much  thickened,  I  ran  it 
fearlessly  and  at  one  stroke,  as  the  less  painful  way,  along  the  whole 
length  of  the  tumor,  when  the  thickest  of  the  yellow  mucus  flowed 
freely  or  was  raked  out  with  the  points  of  the  fingers  and  the  handle 
of  the  bistoury;  and  the  tongue,  descended  now  to  its  natural  level, 
was  in  a  capacity  once  more  of  delivering  the  peculiar  dialect  of  her 
native  city  in  all  its  purity. 

"  So  tense  and  apparent!}'  solid  was  this  tumor,  in  consequence  of 
the  compression  by  so  many  surrounding  muscles,  that  her  surgeon 
mistook  it  for  a  solid  and  strumous  swelling.  I  reckoned  that  in 
this,  as  in  all  cases  of  sacculated  tumor,  the  second  secretion,  which 
was  thinner,  would  wash  out  the  thicker  mucus,  and  I  was  not  de- 
ceived ;  but  she  left  me  too  early  for  me  to  witness  the  obliteration 
of  the  sac. 

"  I  find  it,  in  all  such  cases,  a  matter  of  some  importance,  especi- 
ally in  a  girl,  to  anticipate  the  outward  suppuration  of  any  saccu- 
lated tumor,  by  puncturing  it,  though  to  a  great  depth  within  the 
mouth  and  under  the  tongue,  and  equally  necessary  to  be  at  pains 
in  preserving  the  opening  and  obliterating  the  sac  ;  a  slight  miscon- 


RANULA.  g^y 

duct  in  this  respect  occasions  much  distress  to  the  patient    and 
much  superfluous  labor  to  the  surgeon."  ' 

The  salivary  glands  become  occasionally  the  seat  of  inflammatory 
swellings,  which  are  quite  as  apt  to  become  indolent  as  to  resolve. 
I  have  within  my  own  observation  several  of  these  cases,  and  have 
been  as  many  as  six  months  in  reducing  such  an  induration.  The 
submaxillary,  however,  seems  the  gland  most  disposed  to  take  on 
these  conditions,  and  the  tumefaction  thus  produced  is  without 
rather  than  within  the  mouth,  although  it  not  unfrequently  hai)p('ns 
that  it  is  first  observed  by  the  patient  as  a  hard  body  on  the  inner 
side  of  the  jaw. 

Another  form  of  tumor  which  might  here  be  alluded  to  is  found 
in  the  submaxillary  triangle. 

In  dissecting  down  to  the  su))maxillary  gland,  there  will  be  ex- 
posed, when  the  body  is  uncovered  by  removing  the  superficial  leaf 
of  the  triangular  fascia,  two  lymphatic  ganglia.  These  ganglia  arc 
very  apt  to  indurate,  forming  sometimes  a  tumor  of  considerable 
size.  I  have  met  with  them  as  large  as  a  walnut.  It  is  most  com- 
mon to  mistake  such  indurations  for  hypertrophy  of  the  gland  itself 
Two  diagnostic  signs  distinguish  them  :  they  are  not  triangular,  and 
they  are  not  so  solidly  fixed  as  when  the  gland  itself  is  the  seat  of 
the  enlargement. 

Illustrations. — By  looking  over  and  studying  the  clinical  cases 
following,  I  think  the  general  character  and  manner  of  treatment  to 
be  pursued  in  ranula  and  the  kindred  conditions  must  be  fully  appro, 
ciated. 

"  Ranula. — Operation  by  Dr.  Hamilton.  P.  R.  Cortelyou,  House 
Surgeon. 

"Dec.  13th,   1867.  II ,  of  X.,  aged  10  years,  private  patient. 

admitted  to  Bellevue  under  Dr.  Hamilton's  care. 

"  Soon  after  birth  his  father  noticed  a  swelling  under  bis  chin,  near 
the  median  line,  which  has  continued  to  increase  ever  since.  Now 
the  size  of  a  large  orange,  nearly  in  the  center,  but  inclining  a  little 
to  the  right  side.  It  is  not  painful  or  tender ;  its  surface  is  smooth  and 
elastic.   On  exploration  it  was  found  to  contain  a  thin  yellowish  fluid. 

"  Examining  within  the  mouth,  it  was  found  to  have  lifted  the 
tongue  considerably;  but  its  walls  did  not  present  the  translucent 
appearance  sometimes  seen  in  ranula,  nor  could  it  be  decided  posi- 
tively whether  the  orifices  of  the  ducts,  or  the  right  side,  were  still 
open.  It  became  a  question  what  was  the  source  of  this  enlarge- 
ment or  tumor. 


628  ORAL  DISEASES  A.\W  SlfRGERY. 

"  The  term  '  ranula'  has  been  applied  by  some  surgeons  to  obstruc- 
tions of  the  sublingual  ducts  ;  by  others  to  obstructions  of  the  sub- 
maxillary ducts;  and  by  most  surgeons  to  obstructions  of  either  the 
one  or  the  other  indifferently.  Certain  writers,  also,  have  extended 
the  term  to  all  encysted  tumors  in  this  region,  whether  occurring  in 
the  areolar  tissue  or  in  muciparous  glands,  which  present  a  common 
external  appearance,  like  the  throat  of  a  frog. 

"  It  was  not  very  clear  from  which  of  these  several  sources  this 
tumor  had  originated.  It  was  decided,  therefore,  to  proceed  as  if  it 
were  an  obstructed  duct.  Accordingly,  Dr.  Hamilton  made  a  small 
incision  into  the  tumor  beside  the  tongue,  on  the  right  side,  avoid- 
ing carefully  the  ranine  artery.  This  opening  was  at  once  enlarged 
by  introducing  a  pair  of  bullet  forceps  and  expanding  them,  so  as  to 
tear  the  wound  larger.  The  sac  was  emptied,  and  a  piece  of  lami- 
naria  digitata  introduced.  On  the  third  day  considerable  inflamma- 
tion existed,  extending  to  the  root  of  the  tongue  and  side  of  the  face. 
There  had  been  also,  up  to  this  time,  a  constant  but  slight  hemor- 
rhage. Both  the  swelling  and  bleeding  abated  from  this  time.  The 
contents  of  the  sac  were  examined  under  the  microscope,  but  not 
with  sufficient  care  to  determine  their  character. 

"Feb.  1st,  1868,  nearly  two  months  after  the  operation,  the  father 
reports  that  the  sac  has  almost  disappeared.  A  little  pus  continues 
to  discharge,  and  there  is  no  tenderness  or  swelling.  The  laminaria 
is  taken  out  daily,  and  replaced  with  ease.  It  is  probable  that  the 
complete  cure  will  not  take  place  under  several  months. 

"  Dr.  Hamilton  mentioned  that  a  ranula  was  said  to  form  occa- 
sionally in  a  bursa  outside  of  the  genio-hyoid  muscle ;  but  he  had 
searched  for  this  bursa  and  could  not  find  it." 

"  Swelling  of  Suhmaxillary  Gland  from  Inflammatory  Obstruc- 
tion of  its  Duct. — Charles  D.  Hoyt,  of  Middlesex,  Yates  county, 
called  upon  Dr.  Hamilton,  December  29th,  1846,  with  a  moderate 
enlargement  of  the  right  submaxillary  gland,  it  being  apparently,  as 
felt  beneath  the  jaw,  of  the  size  of  a  large  Lima  bean.  He  stated  that 
this  enlargement  occurred  about  one  week  before,  while  eating  his 
breakfast,  and  that  in  five  minutes  it  attained  the  size  of  a  '  walnut 
with  its  bark  on,'  and  that  it  prevented  his  opening  his  mouth  freely. 
After  leaving  the  table  he  rubbed  it  for  some  time,  and  in  half  an 
hour  it  was  reduced  to  its  present  size. 

"From  that  time  the  same  enlargement  occurred  every  time  he 
ate,  and  without  any  reference  to  what  he  ate.  It  enlarged  most, 
however,  while  eating  his  first  meal  in  the  morning.     By  rubbing 


RANULA. 


629 


alone  could  it  be  reduced.  Chewing  tobacco  seemed  rather  to  dimin- 
ish than  to  increase  its  size.  It  was  not  tender,  nor  red,  but  when 
enlarged  to  its  utmost  it  caused  a  severe  pain,  which  extended  to 
his  ear. 

"  Tinct.  of  iodine  externally  was  first  employed  by  Dr.  H.,  but,  no 
result  being  obtained,  he  directed  him  to  take  a  full  dose  of  Epsom 
salts.  This  had  the  desired  effect.  The  enlargement  disappeared 
very  quickly,  and  did  not  return." 

"  Obstruction  of  both  Submaxillarij  Ducts.— Decemhev  ITth,  1847, 
John  C.  Lyons,  aged  20,  Benton  Center,  Yates  county,  consulted 
Dr.  H.  He  stated  that  in  the  latter  part  of  July,  while  harvesting, 
the  weather  being  very  warm,  he  discovered  in  the  morning  a  sore- 
ness under  his  tongue  upon  the  left  side,  and  before  night  he  found 
there  was  a  tumor  at  this  point.  It  was  oblong  and  only  about  half 
an  inch  in  length.  His  physician.  Dr.  Wolcott,  opened  it  the  fol- 
lowing day,  and  it  discharged  a  glairy  matter.  Since  then  it  had 
been  opened  four  times;  but,  a  few  days  before  calling  on  Dr.  H., 
he  discovered  that  there  was  a  swelling  on  the  opposite  side,  exter- 
nally, in  the  region  of  the  submaxillary  gland.  When  seen  by  Dr.  H. 
the  gland  was  of  the  size  of  a  pullet's  egg,  oblong,  not  painful  or 
tender.  It  was  increasing  in  size,  but  he  noticed  that  it  was  larger 
in  cold  and  damp  weather.  His  health  was  good.  He  was  advised 
to  submit  to  a  low  diet,  take  physic,  and  apply  externally  the  tinct. 
of  iodine.  He  was  never  seen  again,  and  the  result  is  not  known. 
During  the  winter  of  184*7  and  '48,  two  similar  cases  of  enlargement 
of  the  submaxillary  gland  were  presented  in  Dr.  Hamilton's  Surgical 
Clinic,  at  the  Buffalo  Medical  College,  one  of  which  had  resulted  in 
an  external  salivary  fistule. 

"In  a  I'ecent  report  of  one  of  Professor  Jarjavay's  clinics,  copied 
into  the  number  of  the  Gazette  des  Hopitaux  of  November  23d,  1867, 
similar  enlargements  of  the  submaxillary  gland  arc  mentioned  as 
occurring  in  connection  with  obstructions  of  Wharton's  duct ;  but 
he  restricts  the  application  of  the  term  ranula  to  obstruction  of  some 
one  of  the  tweuty-eight  or  thirty  excretory  ducts  of  the  sublingual 
gland." 

Ranula.— In  one  of  a  series  of  interesting  papers  on  "Anatomy 
in  its  Relations  with  Medicine  and  Surgery,"  Dr.  D.  Hayes  Agnew 
makes  the  following  remarks  on  this  subject :  "  A  tumor  is  met  with 
beneath  the  end  of  the  tongue,  rising  from  the  floor  of  the  mouth,  to 
which  the  name  ranula  has  been  applied.  It  involves  the  ducts  of 
the  sublingual  glands,  the  excretory  orifices  of  which  here  open. 


630  ORAL  DISEASES  AND  SURGERY. 

These  become  obstructed  by  some  substance,  either  mechanical  or 
inflammatory,  the  secretion  accumulates  behind,  distending  them 
finally  into  a  semi-transparent  tumor.  Sometimes  they  are  found  to 
be  firm  and  resisting  in  the  texture.  In  such  cases  the  distention 
has  provoked  an  inflammatory  exudation  and  its  organization  into 
fibrous  tissue.  The  transparency  will  depend  upon  the  attenuation 
of  the  mucous  membrane.  The  same  morbid  condition  maybe  pres- 
ent in  a  very  limited  degree,  confined  even  to  a  single  duct,  so  as 
to  resemble  a  little  vesicle.  The  cure  of  such  can  rarely  be  accom- 
plished by  puncture  and  evacuation  of  the  contents :  the  wound  you 
make  will  soon  heal,  and,  as  the  duct  or  ducts  ai*e  not  restored  to  a 
previous  condition,  the  swelling  will  be  reproduced.  No  treatment 
short  of  that  which  contemplates  the  destruction  of  the  glandular 
tissue  will  prove  effectual.  This  is  best  attained  either  by  injection 
or  excision  ;  the  latter  1  think  the  preferable,  which  is  readily  done 
by  including  the  mass  within  two  elliptical  incisions,  and  then  allow- 
ing the  wound  to  heal  by  granulation  or  stitching  the  edges  together 
with  the  finest  silver  wire.  If  it  be  a  small  cyst,  after  clipping  it 
away,  the  point  of  a  stick  of  caustic  may  be  carried  into  the  wound 
for  a  moment  or  so. 

"Another  tumor  is  found  in  this  same  locality,  and  which  is  pro- 
duced by  a  salivai-y  calculus  becoming  arrested  near  the  outlet  of 
the  submaxillar}"  duct ;  and,  last,  another  variety  of  tumor,  w^hich  I 
am  disposed  to  believe  is  rare,  and  being  connected  with  the  under 
surface  of  the  top  of  the  tongue,  rather  than  the  floor  of  the  mouth, 
must  be  referred  to  the  cluster  of  glands  there  situated.  The  sides 
of  the  tongue  may  be  bound  down  by  cicatricial  tissue,  so  as  to  inter- 
fere with  its  proper  functional  movements.  Should  a  nerve-filament 
happen  to  be  included,  it  may  give  rise  to  a  very  painful  condition. 
This  is  best  remedied  by  incisions  or  exsection  of  the  diseased  struc- 
ture." 

Lately,  at  the  Imperial  Society  of  Surgeons  there  was  exhibited 
by  M.  Paulet  two  salivary  calculi  found  by  him  in  Wharton's  duct. 
In  connection  with  the  presentation  was  reported  the  unique  fact — 
for  such  it  was  thought  to  be — that  the  submaxillary  glands  of  both 
sides  were  found  stuffed  with  calculi.  M.  Pana,  however,  presented 
at  the  same  meeting  a  single  calculus  taken  by  excision  from  this 
gland.  It  happens,  also,  that  at  the  present  time  I  have  under  treat- 
ment a  similar  case,  the  first  ever  met  with  by  me.  The  stone  is 
situated  on  the  inside  of  the  mouth,  just  anterior  to  the  ramus  of 
the  left  side. 


RANULA.  (331^ 

PMUula  treated  by  3Iechanical  Pressure. — "Xearly  seven  years 

ago,"  says  Dr.  Wm.  Macdonald,  "J.  F ,  aged  twenty-two  years, 

and  residing  in  M Street,  in  this  city,  consulted  me  in  consequence 

of  being  much  distressed  with  a  ranula,  or  a  large  tumor  under  her 
tongue,  arising  from  an  accumulation  of  saliva  and  mucus  in  the 
ducts  of  the  sublingual  gland.  For  two  years  after  the  period  this 
person  consulted  me,  she  was  attended  both  by  my  professional 
friends  and  myself,  and  that  without  success.  During  these  two 
years  that  this  patient  was  under  the  surgical  and  medical  treatment 
both  of  my  medical  friends  and  myself,  the  following  methods  of 
cure  were  adopted  in  succession :  the  ranula  was  very  often  opened 
with  a  lancet,  and  injections  of  rose-water  and  sulphate  of  zinc  (five 
grains  of  the  sulphate  to  the  ounce  of  rose-water)  injected  by  means 
of  a  syringe,  night  and  morning,  into  the  cavity  of  the  emptied  ranula. 
Occasionally,  when  the  ranula  burst  of  its  own  accord,  and  left  an 
ulcer,  considerable  portions  of  the  sublingual  gland  were  dissected 
out ;  and  on  one  occasion  the  actual  cautery  was  proposed  to  be 
employed  ;  but  the  patient  would  not  consent  to  the  employment  of 
this  method  of  treatment.  During  the  two  years  the  patient  was 
under  treatment  she  took  occasionally  tonics  and  alteratives,  to- 
gether with  laxatives,  as  the  nature  of  her  case  seemed  to  require, 
but  without  any  good  effect. 

"  In  these  critical  circumstances  it  occurred  to  me,  about  five 
years  ago,  that,  if  the  fluid  contained  in  the  ranula  were  completely 
evacuated,  the  employment  of  pressure  over  the  tumor  might  cause 
adhesion  of  almost  all  the  internal  surfaces  of  the  tumor,  except  a 
fistulous  aperture  or  apertures,  analogous  to  the  sublingual  duct, 
through  which  the  saliva  would  necessarily  flow,  and  by  necessary 
consequence  a  radical  cure  would  be  produced,  provided  that  a  per- 
manent adhesion  of  both  surfaces  of  the  ranula  could  be  effected. 

"  In  order  to  produce  such  a  result,  I  proceeded  to  perform  the 
following  operation.  (I  must  remark  that  the  size  of  the  tumor  at 
this  period  was  such  as  to  preclude  the  possibility  of  swallowing 
any  fluid  or  solid  kind  of  food.)  I  introduced  a  bent  needle,  armed 
with  a  ligature,  into  the  ranula,  with  the  view  of  enabling  me  to 
render  the  tumor  steady  while  I  was  opening  it  with  the  lancet,  and 
also  in  order  to  direct  me  afterward  in  injecting  the  ranula ;  this 
being  done,  I  procured  a  common  musket-ball  of  lead,  a  little  flat- 
tened, and  having  a  perforation  through  it,  and  through  this  per- 
foration in  the  bullet  I  introduced  a  yard  or  so  of  common  tape, 
which  was  loosely  tied  around  the  neck  of  the  patient,  while  the 


632  ORAL  DISEASES  AND  SURGERY. 

bullet  remained  in  the  patient's  mouth  and  pressed  by  gravitation 
upon  the  upper  covering  of  the  ranula.  It  is  obvious  that  the  tape 
fixed  to  the  bullet  served  only  the  purpose  of  preventing  the  patient 
from  swallowing  the  bullet  while  it  remained  in  her  mouth.  The 
bullet  thus  kept  in  the  patient's  mouth  night  and  day  for  two  weeks 
produced  union  by  inflammation  (caused  by  mechanical  pressure)  of 
both  surfaces  of  the  ranula,  except  two  fistulous  apertures  analogous 
to  sublingual  ducts,  through  which  saliva  has  flowed  on  each  side  of 
the  fraeuum  of  the  tongue  ever  since ;  and  this  patient  has  happily 
had  no  return  of  her  troublesome  complaint  from  that  period  to  this 
date.  Now,  as  nearly  five  years  have  elapsed  since  the  cure  of  the 
ranula,  we  may  hope  that  the  disease  will  not  again  return." 


CHAPTER    XL. 

PALATINE  DEFECTS   AND   THEIR   TREATMENT. 

In  the  treatment  of  any  palatine  defect,  the  first  consideration  is 
to  be  of  its  cause  and  condition.  Thus,  it  will  be  found  that  such 
defects  or  deficiencies  may,  by  influencing  circumstances,  require 
treatment  so  modified  or  changed  as  to  seem,  in  cases  apparently 
similar,  quite  at  variance  with  each  other. 

For  example,  let  us  takfe  two  perforations  exposing  the  narcs  ; 
one  congenital,  the  other  the  result  of  disease.  Now,  in  the  first  of 
these  cases  we  might  adopt  any  operation  or  appliance  which  would 
seem  to  promise  relief;  while  in  the  second  we  might  justly  pause 
at  any  interference.  No  one  in  his  senses  would  attempt  the  opera- 
tion of  staphyloraphy  on  a  patient  laboring  under  acute  syphilis,  or 
where  a  mercurial  course  had  so  broken  down  the  crasls  of  the  blood 
as  to  make  union  by  the  first  intention  impossible,  or  even  doubtful. 
No  more  would  he  be  justified  in  attempting  this  or  any  other  of  the 
operations  of  expediency,  with  the  constitutional  conditions  adverse 
to  success,  than  he  would  be  justified  in  avoiding  the  responsibility 
where  such  influencing  associations  were  favorable. 

Cleft  Palate. — The  condition  known  as  cleft  palate,  to  which 
we  at  once  pass,  may,  from  its  exceeding  frequency,  be  the  first  to 
claim  attention.  A  cleft  may  be  partial  or  complete ;  that  is,  there 
may  be  a  simple  lengthwise  division  in  that  portion  of  the  mouth 
known  as  the  soft  palate,  or  the  cleft  may  be  so  extensive  as  to  ex- 
tend from  the  uvula  to  the  lip,  a  fissure  separating  both  hard  and 
soft  parts.  The  first  of  these  two  conditions  is  found  perhaps  most 
frequently  as  the  result  of  disease  ;  the  latter  is  nearly  always  con- 
genital. Indeed,  I  do  not  recall  a  single  case  where  I  have  met 
complete  fissure  as  the  result  of  disease.  I  have  treated  fissures 
produced  by  syphilis  where  there  was  a  break  both  in  the  bone 
and  in  the  soft  palate,  but  never  that  I  remember  where  a  coexistent 
break  existed  in  the  continuity  of  the  lip. 

Fissure  of  the  hard  palate  the  result  of  disease,  differs,  however, 
from  congenital  fissure  in  a  particular  which  I  think  would  scarcely 

(633) 


634  ORAL   DISEASES  AND  SURGERY. 

allow  of  the  surgeon  being  deceived.  A  fissure  the  result  of  dis- 
ease exhibits  a  break  in  the  continuity  of  one  or  both  palatine  bones; 
a  fissure  having  congenital  origin  exhibits,  so  far  as  my  experience 
goes,  the  deficiency  at  the  line  of  contiguity  or  in  the  palatine  raphe 
— this  at  least  as  the  rule. 

Let  us  first  consider  the  condition  and  treatment  of  the  congenital 
cleft.  A  child  is  born,  toward  whose  mouth  attention  is  first  di- 
rected either  by  the  nasal  character  of  its  cry,  or  a  little  later,  by  its 
inability  to  take  the  breast  properly,  or,  what  is  by  great  odds  much 
the  most  frequent  case,  the  condition  is  marked  by  the  break  con- 
tinuing through  the  lip,  giving  the  deformity  known  as  hare-lip. 

When  a  child  is  thus,  unfortunately,  born,  and  the  attention  of  the 
surgeon  is  called  to  the  case,  it  seems  to  me  but  a  single  question 
presents  itself  for  his  consideration,  namely,  how  the  deformity 
may  be  corrected:  suffered  to  exist,  every  day  will  increase  the 
difficulty  of  the  cure,  that  is,  so  far  as  the  most  formidable  part  of 
the  operation  is  involved,  while  if  at  once  attempted,  the  prospect 
of  complete  success  is  very  great. 

Fissure  of  the  hard  palate  has  generally  been  deemed  irremedi- 
able, so  far  as  operative  means  are  concerned,  and  the  surgeon  has 
learned  to  consider  his  whole  duty  done  in  describing  to  the  parents 
the  mechanical  method  which  in  after-life  is  to  conceal  and  correct  the 
trouble  of  his  patient.  Now,  in  this  chapter  I  shall  present  a  i-emedial 
surgery  which  is  as  practicable  and  feasible  as  any  other  of  the  oper- 
ations of  expediency,  and  perhaps  I  am  justified  in  going  so  much 
further  as  to  say  that  the  modes  of  procedure  will  be  found  much 
more  promising  than  the  majority  of  such  operations.  Through  the 
proper  application  of  mechanical  allied  with  the  more  strictly  surgical 
means,  I  have  not  unfrequently  succeeded  in  effecting  changes  in  the 
young  maxillary  bones,  a  simple  description  of  which  might  cause 
my  veracity  to  be  doubted  ;  and  yet  this  ability  to  effect  such  changes 
must  become  very  plain  to  us,  if  for  a  single  moment  we  pause  to 
consider  the  difference  between  the  composition  of  the  young  and  that 
of  the  old  bone.  Young  bone,  or  bone  at  birth,  as  is  well  known,  is 
almost  if  not  quite  half  made  up  of  animal  material ;  while  in  the 
osseous  structure  of  the  adult  there  is  an  excess  in  the  limy,  or  unyield- 
ing material,  of  from  seventy-five  to  perhaps  quite  eighty-five  per  cent. 

Let  me  refer  to  the  old  experiment  of  the  maceration  of  bone  in 
dilute  muriatic  acid,  to  illustrate  more  farailiai'ly  this  yielding  con- 
stituent of  bone.  We  know  that  if  we  subject  a  bone  to  the  action 
of  this  acid  for  one  or  two  weeks,  we  may  tie  a  rib  like  a  whip-cord. 


PALATINE  DEFECTS  AND    THEIR    TREATMENT. 


635 


Now,  we  do  this  simply  by  reducing  an  old  bone  to  somewhat  the 
condition  of  a  young  one.  I  have  removed  a  rib  from  a  living  youn«- 
cat,  and  played  with  it  in  this  same  whip-cord  manner.  I  have  per- 
ceptibly bent  the  femur  of  a  young  child  ;  but  no  one,  I  imagine, 
ever  performed  such  a  manipulation  on  the  healthy  femur  of  the 
adult.  You  may  take  an  inferior  maxillary  bone,  even  in  the  child 
of  fifteen  years,  where  the  projection  of  the  chin  is  so  great  as  to  pro- 
duce deformity,  and  with  a  properly-constructed  vertico-racntal  elas- 
tic sling  you  may,  in  a  period  varying  from  three  weeks  to  as  many 
years,  so  change  the  angle  of  the  bone  as  to  do  away  entirely  with 
the  deformity.  You  may  take  the  projecting  myrtiform  border,  and 
through  the  instrumentality  of  the  oceipito-alveolar  sling  you  may 
in  quite  a  short  period  compel  it  to  a  natural  articulation.  On  this 
known  yielding  character  of  the  young  bone,  therefore,  operations 
for  the  correction  of  congenital  fissures  of  the  hard  palate  may  be 
founded. 

A  congenital  fissure  of  the  hard  palate  may  be  corrected  instantly, 
or  the  cure  may  be  effected  slowl3^  The  first  of  these  procedures  is 
applicable  to  such  cases  as  present  but  a  limited  separation  of  the 
bones;  the  latter,  when  the  fissure  has  considerable  width. 

The  operative  procedure  for  the  immediate  cure  is  as  follows:  an 
instrument,  a  modification  of  the  Hoey  clamp,  or  the  ordinary  arte- 
rial compressor,  is  to  be  made  by  so  arranging  the  pads  that  they 
shall  apply  to  the  sides  of  the  jaws  and  allow  of  the  force  being  so 
directed  that  the  pads  can  be  approximated  without  undue  facial 
pressure.  The  clamp  of  Hoey,  it  will  be  seen,  needs  alteration  only 
so  far  as  the  pads  are  concerned,  and  is  quite  easy  of  adjustment  to 
this  purpose. 

The  instrument  ready  (the  patient  being  in  proper  condition),  the 
operator  commences  by  paring  the  soft  parts  and  bone  on  both  sides 
of  the  fissure,  beginning  on  the  approximal  faces  of  the  palate-bones, 
and  cutting  forward  to  the  alveolar  face  of  the  chasm.  This  part 
of  the  operation  completed,  the  little  patient  may  be  allowed  to 
rest  until  the  bleeding  ceases.  The  next  step  is  to  re-etherize  and 
apply  the  compressor,  the  curved  pads  embracing  the  buccal  faces 
of  the  alveolar  arch ;  by  now  gradually  turning  the  screw  of  the 
instrument,  the  yielding  bones  are  brought  together.  The  next  and 
last  step  in  the  operation  is  to  retain  the  parts  in  position  by  the 
use  of  compresses  placed  upon  and  below  the  malar  bones,  and 
secured  by  adhesive  strips  applied  as  in  the  occipito  labial  cravat 
of  Mayo. 


636  ORAL  DISEASES  AND  SURGERY. 

It  may  be  urged  against  these  manipulations  that  they  are  formi- 
dable and  too  heroic  ;  that  fractures  may  result,  etc.  On  these  points 
the  surgeon  must  decide  for  himself.  I  can  only  answer  that,  if  care- 
fully performed,  it  is  not  a  dangerous  operation ;  fracture  of  the 
bone,  even  if  it  should  occur,  would  be  of  little  consequence,  as  the 
parts  have  to  be  kept,  as  it  were,  in  splints,  and  consequently  the 
treatment  of  the  one  would  be  the  treatment  of  the  other.  The  most 
marked  risk  would  be  from  inflammation  that  might  be  provoked ; 
but  a  surgeon  not  unfrequently  has  to  run  far  greater  risk  for  even  a 
less  result. 

Another  mode  of  securing  the  same  end,  which  is  entirely  di- 
vested of  formidable  risk,  is  as  follows :  take  a  circle  of  india-rub- 
ber tubing,  the  circumference  of  which  shall  be  about  one-third  or 
one-half  that  of  the  child's  head ;  next  prepare  two  firm  compresses, 
of  a  size  adapted  to  the  case  under  treatment;  place  these  pads  or 
compresses  one  on  either  cheek,  in  such  position  as  will  give  them 
their  rest  on  the  buccal  faces  of  the  alveolar  arch.  These  being  se- 
cured in  place  by  one  or  more  delicate  strips  of  adhesive  plaster, 
take  up  the  ring  of  rubber  and  pass  it  around  the  cervico-labial  di- 
ameter of  the  head.  Passing  over  the  compresses,  it  will  thus  exert, 
as  is  seen,  a  gradual  pressure,  serving  to  push  the  bone  toward  a 
common  center,  this  center  being  the  mesial  line  of  the  palatine  arch. 
This  process  is  a  gradual  one;  but,  if  the  patient  is  young,  I  think 
it  will  be  found  to  succeed  ;  the  only  real  objection  to  the  manipu- 
lation is  the  constant  care  necessary  to  prevent  excoriation  of  the 
tender  skin. 

When,  by  this  procedure,  the  bony  parietes  have  been  brought 
into  contact,  the  operation,  so  far  as  the  hard  palate  is  concerned,  is 
completed  by  simply  paring  the  folds  of  the  mucous  membrane.  It 
may  or  may  not  be  necessary  to  coaptate  them ;  if  the  bones  have 
been  brought  very  closely  together,  the  granulations  will  alone  be 
sufficient  to  bridge  the  slight  remaining  chasm. 

In  either  of  these  operations  it  is  seen  that  the  break,  both  in  the 
soft  palate  and  lip,  is  not  remedied.  It  is  well,  I  think,  not  to  at- 
tempt the  cure  of  the  lip  until  the  patient  has  entirely  recovered 
from  the  foregoing  operation.  It  may  then  be  performed,  and,  if  done 
according  to  a  rule,  hereafter  suggested,  will  secure  to  the  patient  a 
lip  so  perfect  that,  in  adult  life,  little  or  perhaps  no  mark  of  an  opera- 
tion will  exist.  The  operation  for  the  cleft  in  the  soft  palate  must 
be  left  to  a  period  later  in  life,  for  reasons  presently  to  be  alluded  to. 

These  suggestions  for  the  cure  of  cleft  in  the  hard  palate  were,  I 


PALATINE  DEFECTS  AND    THEIR   TREATMENT.     637 

thought,  original  with  myself,— though  it  is  of  slight  consequence 
who  invents  an  operation,  so  that  it  is  good  ;  but  in  the  periscopic 
department  of  the  Dental  Cosmos  I  find  the  following  extract,  made 
by  Dr.  Ziegler,  from  the  Australian  Medical  Becord  and  Dublin 
Medical  Press,  which  shows  that  the  operation  was  conceived  by 
another  before  it  presented  itself  to  ray  mind.  The  extract  is  a  short 
one,  and  so  apropos  to  the  matter  that  I  shall  take  the  liberty  to  pre- 
sent it  entire : 

"Pressure  in  the  Treatment  of  Cleft  Palate. — I  am  not  aware," 
says  the  author,  "that  the  subject  of  using  pressure  in  treating  fis- 
sure of  the  palate  has  been  before  suggested.  I  am  inclined  to  think 
that  it  has  not ;  for  when  the  plan  first  presented  itself  to  my  mind, 
in  1851,  I  carefully  examined  French,  German,  English,  and  Ameri- 
can works  to  see  whether  it  had.  I  was  first  led  to  try  it  on  the  dead 
body  of  a  child,  which  had  died  three  weeks  after  birth.  The  fis- 
sure was  longitudinal,  and  large  enough  to  admit  the  extremity  of  the 
little  finger;  fissure  of  the  lip  also  existed.  By  means  of  a  pair  of 
clamps,  the  sides  of  the  fissure  were  brought  readily  in  contact, 
without  any  fracture  or  displacement  of  the  bones ;  the  only  fault 
was  that  the  gums  of  the  upper  jaw  were  within  those  of  the  lower; 
but  nature  would  modify  this  as  the  living  child  grew  up ;  the  use 
of  pressure  on  the  lower  jaw  would  remove  a  great  deal  of  this  de- 
formity ;  of  course  the  amount  of  deformity  would  depend  on  the 
size  of  the  fissure  in  the  palate.  I  several  times  repeated  the  exper- 
iments on  young  dogs,  removing  a  piece  of  the  palate-bone  by  means 
of  Key's  saw,  and  then  applying  the  pressure.  The  animals  did 
well. 

"The  operation  should  be  performed  as  early  as  possible  after 
birth,  when  the  bones  are  in  their  softest  condition.  The  following 
is  the  plan  which  I  would  suggest :  the  edges  of  the  fissure  having 
been  pared,  the  superior  maxillary  bones  should  be  embraced  by  a 
horseshoe-shaped  clamp,  with  a  shelf  on  its  lower  border  to  receive 
the  gums  and  prevent  it  slipping.  It  should  be  padded  with  india- 
rubber  or  some  other  material  to  prevent  the  germs  of  the  teeth  bemg 
injured.  The  clamp  should  work  on  a  joint,  and  possess  arms.  It  may 
be  said  to  resemble  a  large  pair  of  pincers  with  horseshoe-shaped 
blades.  A  screw  may  be  attached  at  the  extremities  of  the  handles, 
for  the  purpose  of  bringing  the  blades  in  contact,  or  the  hands  may 
be  used :  the  former  would  be,  I  think,  preferable,  as  the  force  could 
be  applied  gradually,  and  not  be  likely  to  be  carried  too  far.  It  may 
also  be  employed  in  grown-up  children,  when  the  bones  are  so  widely 


638  ORAL  DISEASES  AND   SURGERY. 

separated  as  to  render  it  difficult  to  get  soft  parts  enough  to  close  the 
opening,  but  in  a  gradual  manner  and  at  intervals  more  or  less  pro- 
longed, according  to  the  amount  of  pain  it  excites.  If  it  were  used 
suddenly  it  might  produce  inflammation,  and  subsequently  abscess, 
which  would  prove  troublesome  to  treat.  From  the  foregoing  it 
will  be,  I  hope,  understood  that  the  younger  the  child  the  safer  the 
operation  is  likely  to  prove,  and  that  even  in  grown-up  children  it 
may  be  adopted,  with  precaution,  with  decided  benefit. 

"  The  pads  and  the  ledge  to  rest  the  teeth  upon  should  be  made 
to  slide  in  the  sides  of  the  clamp :  the  former,  that  the  pressure  may 
be  directed  on  any  part  of  the  bones  ;  the  latter,  that  the  edges  of 
the  teeth  may  rest  on  it,  without  the  pressure  being  directed  either 
too  high  or  too  low,  but  at  the  point  where  the  palate-bone  joins  the 
superior  maxillary." 

"We  pass  here  to  the  consideration  of  the  treatment  of  the  fissure 
in  the  soft  palate.  This  operation  is  known  as  staphyloraphy,  a 
term  derived  from  two  Greek  words,  which  signify  suture  of  the 
uvula.  As  generally  practiced,  it  is  rather  difficult  of  performance, 
and  so  frequently  unsuccessful  that  surgeons  seem  disposed  to  avoid 
the  responsibility  of  it.  I  propose  here  to  suggest  for  consideration 
a  new  mode  of  performing  the  operation,  which  renders  the  manipu- 
lations as  easy  of  accomplishment  as  by  the  old  mode  they  are 
tedious  and  difficult. 

Prei^aration  of  the  Patient. — For  weeks  before  it  is  designed  to 
perform  this  operation,  preparations  are  made  for  it,  by  subjecting  the 
parts  to  such  daily  manipulations  as  shall  educate  to  forbearance 
the  natural  sensibility  of  the  fauces.  Without  such  preliminary 
manipulation,  the  retchings  and  spasmodic  twitchings  would  be 
such  as  to  render  a  proper  performance  of  the  operation  almost  an 
impossibility.  With  such  education,  the  parts  will  be  found  to 
assume,  in  a  reasonable  time,  a  stoical  indifference  to  even  quite 
severe  irritants.  This  forbearance  is  secured  by  roughly  fingering 
the  part  daily.  I  think  it  is  not  amiss  to  occasionally  pass  the 
point  of  the  tenaculum  through  the  parts  to  be  operated  upon.  I 
never  knew  the  trifling  wound  to  give  any  trouble ;  and  the  double 
advantage  is  gained,  if  the  part  be  put  on  stretch,  of  securing  an 
estimate  of  the  capability  of  the  velum  to  be  brought  to  the  mesial 
line, — an  important  item  in  the  operation,  as  will  be  easily  appre- 
ciated. Some  surgeons  are  in  the  habit  of  daily  tickling  the  parts 
with  a  fine  brush  ;  this,  I  should  suppose,  would  answer  a  very 


PALATINE  DEFECTS  AND    THEIR    TREATMENT.     639 

good  purpose.  A  very  admirable  idea,  and  a  most  successful  one, 
is  to  have  made  an  obturator,*  which  shall  extend  back  to  the  palate 
border,  or  nearly  to  it.  This  is  to  be  placed  in  the  mouth,  and  as 
soon  as  the  irritability  it  produces  is  so  far  overcome  as  to  permit 
of  its  permanent  retention,  the  bands  attached  to  it  are  to  be  clasped 
firmly  about  the  necks  of  the  teeth,  and  it  is  worn  continuously  for  one 
or  two  months.  When  the  parts  have  thus  submitted  to  the  presence 
of  an  obturator,  they  will  be  found  quite  ready  for  any  operation. 

On  the  evening  before  the  day  of  operation  let  a  saline  cathartic 
be  given  the  patient — particularly  if  he  is  robust  and  strong.  The 
meal  immediately  preceding  the  performance  should,  I  think,  always 
be  a  substantial  one,  for  it  is  to  be  remembered  that  the  patient  is  to 
have  little  to  eat  for  some  time. 

In  operating  on  the  depressed  and  anaemic  patient,  let  his  defici- 
ency in  vital  forces  be  first  considered,  and,  as  far  as  possiljle,  let  it 
be  corrected.  If  such  attention  is  neglected,  we  will  be  almost  sure 
to  make  a  failure :  the  parts  will  not  unite.  Exercise  in  the  open  air, 
generous  living,  and  the  iron  tonics  may  be  prescribed.  To  sum  all 
up  in  a  single  sentence,  the  preliminary  treatment  must  meet  the  in- 
dications of  each  particular  case.  If,  for  example,  you  should  operate 
on  a  scorbutic  patient,  or  a  patient  disposed  to  purpura,  without  cor- 
recting such  dyscrasis,  you  would  be  no  more  likely  to  gain  union  of 
the  parts  brought  together  than  in  an  operation  on  the  cadaver. 

The  surgical  anatomy  of  the  part  is  required  fully  to  Ijc  under- 
stood. So  much  of  success  depends  on  a  thorough  knowledge  of  the 
muscular  relation  to  the  cleft  that  such  acquaintance  would  give  a 
success  where  otherwise  a  failure  would  be  sure  to  result.  This 
anatomy  we  may  study  before  taking  up  the  steps  of  the  operation. 

To  get  a  correct  idea  of  the  soft  palate,  we  should  commence  the 
study  of  it,  by  first  carefully  examining  the  parts  on  the  living  sub- 
ject. When  we  look  into  a  living  mouth,  we  see  an  arch  stretching 
from  every  portion  of  the  alveolar  edge  backward  and  inward,  to- 
ward the  fauces,  terminating  in  a  tongue  or  uvula,  pendant  in  a 
horizontal  direction  from  its  center.  One-half  of  this  arch  is  seen  to 
be  fixed,  the  other— the  posterior  half— is  seen  to  be  in  almost  con- 
stant motion.  If,  now,  the  finger  is  carried  into  the  mouth,  the 
fixed  part  is  found  to  correspond  with  the  boundaries  of  the  palatine 
faces  of  the  maxillary  and  palate  bones ;  that  is,  for  a  certain  ex- 


A  description  of  tliis  instrument  and  of  its  proper  use  will  hereafter  be 


jTiven. 


640  ORAL  DISEASES  AND  SURGERY. 

tent,  you  feel  that  the  parts  are  solid,  as  if  the  fing-er  passed  over  an 
arch  of  bone  which  might  be  covered  alone  by  mucous  membrane ; 
and  this  is  in  fact  about  the  case.  The  finger  traverses  the  anterior 
bony  border  of  the  mouth,  or  the  hard  palate.  As  now  the  finger 
is  passed  backward,  it  falls  over  a  hard  ridge  upon  parts  that  are 
soft  and  yielding ;  this  hard  ridge  is  the  posterior  face  of  the  palate- 
bone,  and  terminates  the  hard  palate.  The  part  upon  which  the 
finger  has  fallen  is  the  veil  or  soft  palate,  the  part  that  was  observed 
to  be  movable.  This  is  the  part  in  which  occurs  the  rent,  or  cleft, 
for  the  cure  of  which  is  demanded  the  operation  we  are  about  to 
consider. 

The  mobility  of  this  part,  which  pertains  to  its  function,  depends, 
as  may  be  anticipated,  on  an  associated  muscular  structure.  To 
study  properly  this  structure,  which  is  all-important  to  be  practically 
understood  and  appreciated,  the  student  should  take  up  the  scalpel 
and  pass  to  the  cadaver ;  it  is,  perhaps,  only  by  dissecting  that  a 
really  satisfactory  idea  of  these  muscles  can  be  secured, — that  is,  as 
pertains  to  that  kind  of  knowledge  which  gives  confidence  when  we 
come  to  perform  operations  upon  the  part. 

The  external  coat  or  covering  which  we  see  on  every  mouth, 
living  or  dead,  is  the  mucous  membrane ;  simply  the  continuation  of 
that  which  covers  the  hard  palate  ;  but  while  in  the  case  of  the  hard 
palate  we  find  all  the  underlying  structure  osseous,  in  the  soft  palate 
we  discover  this  deep  tissue  to  be  made  up  exclusively  of  muscular 
tissue — at  least  as  far  as  a  surgical  anatomy  is  concerned,  or  as  it 
alone  serves  our  purpose  here  to  study  it. 

Commencing  with  the  mesial  line,  we  can  dissect  out  the  attach- 
ment of  five  muscles,  each  of  which  is  of  course  duplicated  on  the 
opposite  side,  and  each  of  which  has  such  relation  to  this  mesial 
line  that,  in  case  of  cleft  or  split,  it  serves  more  or  less  to  draw  away 
the  parts  postero-laterally. 

These  muscles,  mentioned  in  the  order  of  their  signification  to  this 
lateral  displacement,  and  consequently  in  their  relation  to  the  opera- 
tion of  staphyloraphy,  are  tensor  palati,  palati  glossal,  levator  palati, 
palati  pharyngeal,  motores  uvulse.  But  of  all  these  muscles  the  tensor 
palati  plays  the  most  important  part,  and  is  therefore  entitled  to 
closest  consideration. 

This  muscle  arises  from  the  scaphoid  fossa  at  the  root  of  the  in- 
ternal pterygoid  plate,  from  the  anterior  surface  of  the  Eustachian 
tube,  and  from  the  spinous  process  of  the  sphenoid  bone.  If  you 
carry  your  finger  (in  your  own  mouth)  back  to  the  wisdom  tooth  of 


PALATINE  DEFECTS  AND    THEIB    TREATMENT.     641 

the  superior  jaw,  and  let  it  drop  over  and  back  of  this  tooth,  it  will 
fall  on  the  tuberosity  of  the  maxillary  bone ;  carry  it  now  half  an 
inch  farther  back,  and  it  will  come  to  a  second  prominence ;  this  is 
the  haniular  process  of  the  pter^-goid  plate  of  the  sphenoid  bone. 
Now,  the  tensor  palati  muscle  descends  from  the  origin  of  which  we 
have  just  informed  ourselves,  and  meetijig  this  hamular  process,  it 
winds— as  a  tendon — around  it,  and  then,  by  a  fanlike  expansion, 
spreads  itself  over  the  soft  palate.  Its  action  is  evident:  it  expands 
the  palate  laterally. 

To  perform  successfully  the  operation  for  cleft  palate,  it  is  per- 
haps desirable,  in  every  case,  that  the  strain  made  by  this  muscle 
should  be  taken  off.  A  moment's  reflection  will  show  us  that  the 
action  of  the  muscle,  in  case  of  a  cleft,  would,  when  the  parts  were 
brought  together,  be  much  increased  over  its  natural  capability,  not 
only  because  it  would  be  put  considerably  on  the  stretch,  but  be- 
cause such  stretch  would,  more  than  likely,  excite  it  to  a  spasmodic 
contraction.  The  muscle  of  course  is  then  to  be  divided ;  and  we 
may  as  well  here,  as  anywhere,  consider  the  easiest  point  at  which 
such  preliminary  operation  can  be  done. 

We  remarked  of  the  muscle  that  it  would  be  found  winding — as 
a  tendon — around  the  hamular  process.  It  winds  from  the  back, 
and  outwardly,  inward,  and  forward,  so  that  just  in  front  of  the 
process,  between  it  and  the  tuberosity,  is  the  place  at  which  its 
section  may  be  best  performed ;  there  are  here  no  important  vessels 
to  be  wounded,  if  we  except  the  posterior  palatine  artery  and  nerve, 
and  they  hug  the  base  of  the  tuberosity  so  closely  that  it  would,  I 
think,  have  to  be  a  very  badly  managed  knife  that  should  interfere 
with  either  of  them.  The  cut  should  be  a  little  oblique.  The  inter- 
ference with  function,  as  in  most  cases  of  myotomy  or  tenotomy, 
would  be  of  course  but  temporary.  The  action  of  the  muscle  would 
be  found  recovered  quite  as  soon  as  our  cleft  operation  would  be 
ready  for  it. 

The  next  most  important  muscle  is  the  palato-glossal ;  this  is  sim- 
ply the  anterior  half  arch,  the  constrictor  isthmii  iaucium.  It  arises, 
as  will  be  seen,  from  the  soft  palate  on  either  side  of  the  uvula,  and, 
passing  outward,  is  inserted  into  the  sides  of  the  tongue,  blending 
with  the  fibers  of  the  stylo-glossus  muscle. 

The  palato-pharyngeus  arises  from  the  soft  palate,  by  an  expanded 
fasciculus,  and,  passing  outward,  goes  to  be  inserted  into  the  poste- 
rior borders  of  the  thyroid  cartilage.  These  muscles  constitute  the 
posterior  half  arches.     Section,  both  of  the  palato-pharyngeus  and 

41 


642  OEAL  DISEASES  AND  SURGERY. 

the  palato-glossal,  is  to  be  made  through  the  substance  of  the 
muscle,  and  is  accomplished  simply  by  nicking,  somewhat  deeply, 
the  arches — four  cuts,  one  to  each  arch.  These  nicks  are  best  made 
with  scissors. 

The  Levator  Palati. — This  muscle  arises  from  the  petrous  portion 
of  the  temporal  bone,  passes  into  the  interior  of  the  pharynx,  and 
then  descends  obliquely  downward  and  inward,  spreading  its  fibers 
out  over  the  posterior  surfaces  of  the  soft  palate  as  far  as  the  raphe. 

The  action  of  the  fifth  and  last  muscle,  the  azygos  uvulae,  it  is  per- 
haps not  absolutely  necessary  to  consider — its  influence,  for  separa- 
tion of  the  wound,  being  very  trifling. 

Section  of  the  levator  palati  is  thought  to  be  easiest  of  perform- 
ance after  the  manner  suggested  by  Mr.  Pollock.  This  gentleman 
first  puts  the  flap  on  stretch,  and  then,  with  a  double-edged  knife, 
makes  an  incision  through  the  soft  palate  just  on  the  inner  side  of 
the  hamular  process.  The  handle  is  now  alternately  elevated  and 
depressed,  a  sweeping  cut  being  made  along  the  posterior  surface  of 
the  soft  palate. 

The  other  anatomical  elements  of  the  soft  palate  are  glandular 
structures,  vessels,  nerves,  etc.,  all  associated,  more  or  less  inti- 
mately, by  connective  tissues ;  but  these  need  not  be  particularly 
referred  to,  as  one  could  not  well  dissect  out  the  muscles  without 
necessarily  familiarizing  himself  with  them.  Thus,  then,  we  under- 
stand the  surgical  anatomy  proper  of  the  parts — the  anatomy  as  it 
has  relation  to  cleft  palate. 

The  operation  of  staphyloraphy  was  first  practiced  by  a  dentist  of 
Paris,  La  Monier, — if  I  remember  the  name  rightly.  It  has  for  its 
object  the  bringing  together  of  the  separated  portions  of  a  cleft  soft 
palate,  and  the  retention  of  the  parts  in  apposition  until  nature  shall 
unite  them. 

The  operation  consists  of  four  difi'erent  stages,  with  an  object  to 
be  attained  by  each  stage  : 

1st.  The  paring  off  of  the  edges  of  the  cleft. 

2d.  The  introduction  of  ligatures. 

3d.  The  bringing  together  of  the  freshened  edges,  and  fixing  the 
ligatures. 

4th.  The  relief  of  any  tension  on  the  ligatures  that  may  attend  the 
approximation  of  the  parts. 

These  are  the  steps  or  stages,  and  to  accomplish  them  various 
means  and  instruments  have  been  devised — some  good,  some  bad, 
some  indifferent.     The  reader  curious  in  such  matters  will  find  an 


PALATINE  DEFECTS  AND    THEIR    TREATMENT.     643 

admirable  and  most  instructive  chapter  on  the  subject  in  the  System 
of  Surgery,  published  in  1851,  by  Professor  H.  H.  Smith  of  the 
IJniversity  of  Pennsylvania.  In  the  chapter  therein  devoted  to 
staphyloraphy  is  given  a  synopsis  of  the  operations  as  practiced 
by  surgeons  whose  names  have  been  and  are  particularly  associated 
with  the  subject. 

An  epitome  may  be  made  of  this  chapter  by  noticing  that  the  oper- 
ation first  suggested  by  La  Monier,  in  1764,  was  revived  by  Graefe, 
of  Berlin,  in  1817,  but  first  methodized  and  puldished,  with  the  rules 
for  its  performance,  by  Roux,  of  Paris,  about  1819.  In  1820  a  nearly 
similar  operation  was  performed  by  Dr.  John  C.  Warren,  of  Boston, 
he  being  at  that  time  ignorant  of  the  views  or  operations  of  other 
surgeons.  In  many  respects  the  steps  proposed  by  Drs.  Warren  and 
Eoux  correspond,  though  the  means  suggested  by  Dr.  Warren  are 
simplest — the  operation  of  the  latter  being,  however,  generally  re- 
garded as  the  basis  of  the  various  modifications  that  have  since  per- 
fected the  proceeding. 

The  instruments  prepared  by  Roux  for  performing  the  operation 
are  alluded  to  as  being  sufficiently  complicated.  To  execute  the  man- 
ipulations, he  seated  his  patient  before  a  strong  light,  with  his  head 
thrown  back  and  supported  against  the  chest  of  an  assistant— the 
mouth  being  kept  widely  open  by  means  of  a  cork  placed  between 
the  molar  teeth.  The  surgeon  then  placed  himself  in  front,  and, 
with  forceps  held  in  the  left  hand,  seized  the  right  lip  of  the  fissure. 
With  his  right  hand  armed  with  a  needle-holder,  he  next  introduced 
the  point  of  the  needle  from  before  backward  behind  the  uvula,  in 
order  to  traverse  the  flap  from  behind  forward,  at  three  or  four  lines 
from  the  free  edge  of  the  fissure.  The  needle,  being  thrust  in  as  far 
as  its  head,  was  then  freed  from  the  needle-holder,  and  seized  at  its 
point  by  forceps,  which  drew  it  and  the  ligature  through  into  .the 
mouth.  After  permitting  a  few  minutes  of  rest  to  the  patient,  the 
same  manoeuvre  was  practiced  on  the  left  side  of  the  fissure  with  the 
other  needle  of  the  same  ligature,  the  two  ends  of  which  were  thus 
brought  out  into  the  mouth.  In  passing  these  ligatures,  M.  Roux 
commenced  with  the  lowest,  next  passed  to  the  highest,  and  ended 
with  the  middle. 

The  next  step  in  the  operation  of  Roux  was  to  freshen  the  edges 
of  the  fissure.  This  he  accomplished  by  seizing  the  margins,  as  be- 
fore, with  his  forceps,  and  paring  from  behind  forward. 

To  tie  the  ligatures,  this  surgeon  commenced  by  knotting  the  mid- 
dle one  with  the  fingers,  and,  after  making  a  simple  knot,  confiding 


644  ORAL   DISEASES  AND  SURG  ERF. 

it  to  an  assistant,  wlio  hold  it  with  an  instrument  termed  by  the 
French  a  serre-noeud  (knot  tier)  ;  he  then  passed  on  to  the  second 
ligature,  and  from  that  to  the  first,  drawing  them  tighter  than  is 
necessary  to  approximate  the  edges  of  the  wound,  in  order  to  pre- 
vent any  separation.  Eating,  drinking,  and  speaking  were  inter- 
dicted the  patient  for  from  two  to  three  days,  the  ligature  being 
removed  on  the  third  or  fourth  day,  excepting  the  lowest  one,  which 
was  allowed  to  remain  twenty-four  hours  longer  than  the  other. 

Dr.  John  C.  Warren  performed  the  operation  as  follows.  The 
patient  being  well  supported  and  secured,  a  piece  of  wood,  an  inch 
wide,  a  little  curved  at  the  end,  and  with  a  handle  to  be  held  by  an  as- 
sistant, was  placed  on  the  molar  teeth  of  one  side,  to  keep  the  mouth 
open.  A  sharp-pointed  curved  bistoury  was  then  thrust  through 
the  top  of  the  palate,  above  the  angle  of  the  fissure,  and  carried  down 
on  one  edge  of  the  cleft  to  its  extremity,  and  the  same  was  done  on 
the  opposite  side,  so  as  to  cut  out  a  piece  in  the  form  of  a  letter  Y, 
including  about  a  line  from  each  edge.  Next  a  hook,  or  curved 
needle,  fastened  in  a  handle,  with  an  eye  on  its  extremity,  and  a  mov- 
able point,  armed  with  a  triple  thread  of  strong  silk,  was  passed 
doubled  into  the  mouth  through  the  fissure  behiud  the  palate,  and 
the  latter  pierced  by  it  one-third  the  length  of  the  fissure  from  the 
upper  angle  of  the  wound,  so  as  to  include  about  three  lines  of  the 
edge  of  the  soft  palate.  The  eye,  with  the  ligature,  being  seen,  was 
seized  with  a  common  hook  and  drawn  out.  The  eyed  hook  was 
then  drawn  back,  turned  behind  the  palate,  and  the  other  edge  trans- 
fixed in  a  similar  manner.  A  second  and  a  third  stitch  was  now  passed 
in  a  similar  manner,  the  third  being  as  near  as  possible  to  the  lower 
end  of  the  fissure.  Then,  seizing  the  upper  ligature  with  the  finger, 
the  knot  was  tied  without  using  a  serre-nceud,  and  placed  on  one 
side  of  the  wound  in  order  to  prevent  its  pressing  on  the  fissure,  the 
other  being  tied  in  like  manner,  and  the  fissure  closed. 

After  the  first  operation  of  Dr.  Warren,  Dr.  A.  H.  Stevens,  of 
New  York,  September,  1826 — see  North  American  Medical  Jour- 
nal, vol.  iii.  p.  233 — operated  successfully,  by  first  inserting  the  liga- 
tures and  then  paring  the  edges. 

In  1827,  Dr.  Mettauer,  of  Yirginia,  operated  for  staphyloraphy, 
and  in  1837  published  an  excellent  essay.  Dr.  M.  employed  leaden 
ligatures :  see  American  Journal  of  Medical  Science,  vol.  xxi.  p.  309. 

Allusions  are  made  in  this  chapter  to  other  operators  and  opera- 
tions; but,  as  they  are  all  only  modifications  of  the  methods  of  Roux 
and  Warren,  it  is  not  necessary  to  refer  to  them. 


PALATINE  DEFECTS  AND    THEIR    TREATMENT. 


645 


Several  years  back  I  remember  having  in  my  possession  a  mono- 
graph on  the  subject  of  staphyloraphy,  from  the  pen  of  the  late  Pro- 
fessor Miitter.  I  regret  that  I  cannot  now  lay  my  hands  upon  it. 
Dr.  Miitter  was  much  interested  in  the  operation,  and  his  pamphlet, 
as  I  recall,  abounded  in  cases  illustrating  his  success  in  this  direc- 
tion. 

To  Mr.  Fergusson,  of  England,  however,  more  than  to  any  other 
man,  are  we  perhaps  indebted  for  a  scientitic  appreciation  of  the  re- 
quirements in  staphyloraphy.  The  cutting  and  sewing  parts  of  the 
operation  are  simple  mechanical  manipulations,  which  are  of  conse- 
quence only  as  they  tax  the  ingenuity  of  the  surgeon.  The  proper 
surgical  understanding  of  the  subject  consists,  as  we  are  prepared  to 
see,  in  a  just  acquaintance  with  the  muscular  relations  of  the  parts. 
These  relations  we  have  already  studied.  To  Mr.  Fergusson  belongs 
the  credit  of  first  making  these  demonstrations.  It  is  very  true  that 
before  his  time  incisions  in  the  soft  parts  had  been  advised.  Roux, 
Dieffenbach,  Mettauer,  Liston,  and  Warren  all  practiced  them  where 
difficulty  was  met  within  approximating  the  fissure;  but  the  incision 
practiced  by  them,  as  remarked  by  Mr  Fergusson,  seems  to  have 
been  without  reference  to  the  anatomy  of  the  parts,  and,  as  a  conse- 
quence, rendered  success  somewhat  a  matter  of  accident.  The  oper- 
ation of  Mr.  Fergusson,  so  far  as  the  paring  and  bringing  of  the 
fissured  parts  together  are  concerned,  is  about  the  same  as  that  prac- 
ticed by  Dr.  Warren.  He  pares  the  cleft  before  inserting  his  sutures, 
and  his  knots  are  made  about  as  Dr.  Warren's. 

In  looking  over  the  history  of  staphyloraphy,  the  reader  will  be 
struck  with  the  likeness  in  complaints,  the  three  principal  of  which 
seem  to  be — the  difficulty  in  tying  the  ligatures,  the  great  tendency 
of  the  ligatures  to  slough  out  after  they  are  once  nicely  secured, 
and  the  concealment  of  the  parts  during  operation,  both  because 
of  deficiency  in  light  and  the  accumulation  of  the  viscid  muco-saliva 
which  in  mouths  thus  affected  is  secreted  in  such  abundance. 

Now,  in  the  direction  of  operations  in  and  about  the  oral  cavity 
I  have  had  that  experience  and  that  practice  which  will,  perhaps, 
justify  me  in  asserting  that  there  is  an  easier  and  more  philosophi- 
cal mode  of  performing  the  operation  of  staphyloraphy  than  has  yet 
been  practiced.  To  sit  in  front  of  a  patient  and  operate  in  the  mouth 
is  most  unhandy.  The  operator  is  in  his  own  light;  besides,  it  is 
certainly  much  more  difficult  to  operate  sitting  than  standing— mo- 
tion is  cramped,  freedom  is  interfered  with.  To  operate  on  the 
mouth  of  a  patient,   when  the  surgeon  is  seated  in  front,  makes 


646  ORAL  DISEASES  AND  SURGERY. 

necessary  an  assistant,  whose  office  it  is  to  manage  the  head.  This 
has  a  twofold  objection.  In  the  first  place,  the  assistant  cannot  fol- 
low in  all  those  little  changes  which  are  so  necessary  to  success. 
He  docs  not  see  quickly  the  shiftings  and  turnings  which  so  assist 
in  the  manipulations.  Again,  one  is  more  naturally  ambidextral 
when  the  arms  are  supported  than  when  they  are  unsupported.  In 
operating  by  sitting  in  front  of  a  patient,  the  surgeon  must  work  at 
arm's  length ;  he  has  nothing  to  steady  him — no  guard  which  shall 
enable  him  to  shield  himself  against  any  sudden  awkward  movement 
on  the  part  either  of  the  assistant  or  the  patient. 

To  make  a  knot  in  a  deep  canal,  such  as  the  mouth  or  vagina,  is 
not  easy.  To  fix  a  ligature  by  compressing  something  upon  it 
is  very  simple.  Silk  acts  as  an  irritant  to  human  tissue-^silver 
or  lead  does  not ;  therefore,  where  it  is  desirable  to  retain  a  liga- 
ture for  several  days  or  weeks,  without  irritation,  metal  is  best 
adapted. 

Instruments  perfectly  suited  to  an  operation  simplify  it  greatly. 

Predicating  an  operation  on  these  self-evident  truths,  I  commend 
the  following  as  the  best  and  easiest  mode  of  manipulating,  believing 
that  where  once  practiced  it  will  take  precedence  of  all  other  modes. 

The  instruments  required  are  those  belonging  to  the  ordinary 
vesico-vaginal  case, — the  long-handled  knife,  needles,  and  needle- 
carrier,  shot-carrier  and  compressor,  tenaculum,  cutting  forceps,  sil- 
ver or  lead  wire,  the  little  perforated  flat  shot  of  McLean,  and  mop 
sticks.  Better  instruments  than  these  for  the  operation  of  staphylor- 
apby  will  not,  I  think,  ever  be  devised.  The  instruments  arranged  on 
a  tray  in  the  order  in  which  they  are  to  be  used,  the  patient,  having 
the  steps  of  the  operation  explained  to  him, — for  much  is  expected 
from  him, — is  seated  on  a  chair  having  a  movable  head-rest ;  it  is  well 
if  this  rest  moves  in  a  ball-and-socket  joint — at  any  rate,  it  must  be 
movable  backward  and  forward.  The  ordinary  dental  chair  answers 
the  purpose  admirably.  When  the  head  is  placed  on  this  rest  the 
mouth  will  be  found  to  look  directly  upward.  The  surgeon  now 
takes  his  position  back  of  the  patient,  standing  on  a  footstool  of 
such  height  that  his  breast  shall  be  brought  on  a  level  with  the 
head  of  the  patient.  If  the  reader  is  disposed,  he  can  thus  seat  a 
friend,  and,  taking  a  position  back  of  him,  by  leaning  over  his  head 
he  will  find  that  when  the  mouth  is  opened  he  not  only  has  a  most 
perfect  view  of  a  thoroughly  lighted  cavity,  but  by  leaning  against 
him,  and  passing  his  arms  around  the  head  so  as  to  bring  the  hands 
to  the  mouth,  he  will  recognize  that,  besides  having  h-is  own  arms  so 


PALATINE  DEFECTS  AND    THEIR   TREATMENT.     047 

steadied  as  to  allow  of  the  easiest  manipulation,  he  has  the  move- 
ments of  the  patient  completely  under  his  control. 

Now,  this  relative  position  of  the  surgeon  to  his  patient  gives  him 
not  only  the  advantages  enumerated,  but  he  is  out  of  the  way  of  all 
expectorative  efforts.  If  saliva  and  blood  should  accumulate  about 
the  parts  at  which  he  is  working,  he  -can  and  will,  almost  uncon- 
sciously, and  certainly  Avithout  effort,  so  turn  the  head  that,  while 
he  does  not  at  all  interfere  with  his  own  manipulations,  he  throws 
the  fluid  into  some  more  convenient  part  of  the  mouth.  This,  I 
know,  can  be  done  so  readily  that  each  step  of  the  operation  may 
be  accomplished  without  the  annoyance  and  delay  experienced  in 
using  the  mop.  Certainly,  a  patient  so  held  cannot  make  any  move- 
ment too  quickly  or  too  unexpected  for  the  surgeon.  True,  he  might 
be  so  obstreperous  that  the  operation  could  not  be  accomplished ;  but 
he  could  not  make  any  movement  which  the  knife  of  the  operator 
could  not  naturally  follow,  and,  therefore,  any  accidental  harm  could 
not  be  done. 

Patient  and  surgeon  thus  in  position,  the  tenaculum  is  taken  up 
and  carried  through  the  very  point  of  the  cleft  pendulum.  The 
part  is  then  put  on  stretch,  and  a  paring  of  about  a  line  taken  from 
the  whole  of  that  side,  cutting  from  behind  forward.  The  manii)u- 
lation  is  Repeated  on  the  opposite  side.  The  first  stage  completed, 
tincture  of  iodine,  diluted  to  about  one-tenth  its  officinal  strength  with 
wine  or  water,  is  given  the  patient  with  which  to  gargle  and  wash 
the  mouth.  This  I  find  to  cleanse  the  mouth  adniira])ly ;  besides,  it 
is  a  fine  healthy  stimulant. 

The  bleeding  arrested  and  the  patient  a  little  recovered,  the  second 
step  of  passing  the  ligature  may  be  attempted.  Take  up  one  of  the 
curved  needles,  and,  threading  it  with  the  silver  wire,  fix  it  in  the 
needle-carrier.  Passing  now  the  instrument  into  the  mouth,  thrust 
the  needle  through  one  side  of  the  cleft,  about  three  lines  from  the 
margin  and  about  half  an  inch  from  the  apex  of  the  cleft  or  hard 
palate.  After  passing  it  to  the  point  at  which  it  is  held  by  the 
carrier,  it  is  to  be  caught  by  the  forceps  and  brought  through,  the 
slide  of  the  porte  being  loosened  so  as  to  permit  of  such  withdrawal 
of  the  needle  from  its  beaks.  This  accomplished,  the  needle  is  to 
be  replaced  in  the  porte  and  carried  through  the  opposite  side ;  re- 
lieving it  from  the  grasp  of  the  carrier  as  before,  the  two  ends  are 
brought  from  the  mouth  and  their  relation  secured  by  one  or  two 
twists.  This  completes  the  first  ligature.  A  second  is  now  passed 
half  an  inch  farther  on,  also  a  third,  or  more,  as  may  seem  needed. 


648  ORAL  DISEASES  AND   SURGERY. 

The  manipulations  required  are  of  course  the  same  as  for  the  first. 
This  completes  the  second  stage,  and  the  patient  is  allowed  to  rest 
as  before.  If  he  needs  to  wash  his  mouth,  the  surgeon  must  look 
carefully  after  his  ligatures. 

The  third  stage,  or  approximation  of  the  edges,  is  next  to  be 
accomplished.  Take  up  the  shot-carrier,  and,  slipping  through  its 
fenestra  the  twisted  ends  of  the  first  ligature  introduced,  push  the 
carrier  down  the  wires,  and  you  will  find,  as  it  approaches  the  palate, 
the  edges  of  the  cleft  approximate.  This  I  think  will  always  be 
found  to  be  the  case  wnth  the  ligature  nearest  the  hard  palate  :  the 
parts  come  together  very  easil}^  You  now  slip  off  the  carrier  and 
take  up  one  of  the  perforated  shot ;  put  this  on  the  wires,  and  with 
the  carrier  force  it  down  to  the  palate.  Holding  it  now  in  place, 
which  is  done  simply  by  laying  the  wires  against  the  carrier  and 
shifting  your  finger  over  it,  take  up  with  the  right  hand  the  forceps,' 
and  compress  the  shot  tightly  upon  the  wires.  The  parts  up  to  this 
ligature  will  now  be  found  nicely  approximated  and  fixed.  This 
completed,  repeat  the  operation  on  the  second  ligature.  But  this 
will  be  found,  pcrhajjs,  impossible,  without  greatly  overstraining 
the  parts  and  risking  the  tearing  out  of  the  wire. 

If  this  is  the  case,  you  at  once  desist  from  the  attempt,  and  make 
the  section  as  described  of  the  tensor  palati  muscles  on  either  side. 
Now  most  likely  the  parts  will  come  together  comfortably:  if  so,  fix 
them  with  the  shot  as  before ;  if,  however,  an  approximation  has 
not  yet  been  secured,  nick  the  anterior  half  arch ;  and  if  this  does 
not  suffice,  cut  the  posterior  and  the  levator  palati ;  the  ligature  may 
then  be  fixed,  as  well  as  those  still  farther  back.  Each  shot  firmly 
compressed,  the  wires  are  to  be  cut  off  as  closely  as  possible.  Thus 
the  third  and  fourth  steps  of  the  operation  are  completed,  and 
nothing  remains  but  to  enjoin  on  the  patient  the  most  perfect  rest. 
Herein  lies  half  the  secret  of  success :  the  patient  should  scarcely 
move  for  two  or  three  days;  certainly  he  should  not  be  permitted 
any  food  that  would  demand  for  its  comminution  the  slightest  effort 
of  mastication.  He  should  be  directed  to  allow  the  liquids  he  may 
take  to  trickle  down  his  throat,  rather  than  to  attempt  to  swal- 
low them.  These  restrictions  need  not,  however,  be  made  quite 
.so  strict,  if  in  the  operation  myotomy  of  the  half  arches  has  been 
performed. 

In  the  old  mode  of  performing  the  operation,  it  was  found  neces- 
sary after  the  first  one  or  two  days  to  remove  the  ligatures  because 
of  their  tendency  to  slough  out:  the  use  of  silver  wire  obviates  this 


PALATINE  DEFECTS  AND    THEIR    TREATMENT. 


649 


necessity,  as  the  metal  seems  to  provoke  no  iiiflammation.  These 
ligatures  may  therefore,  if  they  seem  useful,  be  allowed  to  remain 
from  one  to  three  weeks.  This  non-irritating  quality  of  the  metal 
ligature  is  so  marked  that  I  have  seen  them,  when  applied  on  vari- 
cose veins,  as  firmly  fixed  after  four  months  as  the  first  day  they 
were  put  on.  This  is  the  feature  which  adapts  them  so  admirably 
for  sta])hyloraphy. 

The  wounds  made  in  dividing  the  muscles  may  be  left  to  nature. 
If  the  patient  is  in  condition  for  the  principal  operations,  he  is 
in  a  condition  which  does  away  with  any  necessity  for  care  in 
trifling  flesh-wounds ;  if,  however,  any  trouble  should  arise  in  such 
a  direction,  the  practice  would  be  that  which  would  apply  to  similar 
wounds,  however  made. 

It  is  seen  that  the  manipulations  here  suggested  for  the  cure  of 
cleft  palate  are  precisely  the  same  as  those  practiced  in  vesico-vaginal 
fistula,  and  that  the  instruments  adapted  to  the  one  are  exactly  suited 
for  the  other. 

The  position  in  operating  is,  I  think,  a  new  suggestion,  and  is 
founded  on  a  somewhat  extended  experience  in  manipulating  upon 
and  about  the  mouth.  To  me  it  seems  the  most  proper  position  for 
performing  the  operation  easily  and  comfortably  ;  the  advantages 
which  it  possesses  over  the  old  mode  of  sitting  down  in  front  of  the 
patient  are  so  easily  studied  upon  the  person  of  any  one,  that  I  trust 
the  suggestion  will  receive  the  attention  I  think  it  will  be  found  to 
merit.* 

With  this  consideration  of  cleft  palate  proper,  we  may  pass  to  the 
study  of  other  defects  of  the  parts. 

Holes  in  the  Palate. — Breaks  in  the  continuity  of  the  palate 
maybe  treated  in  two  ways:  either  by  an  operation  strictly  sur- 
gical, as  reference  may  be  had  to  the  use  of  the  knife,  or  by  means 
which  might  be  denominated  surgico-mechanical.  If  the  knife  is  to 
be  exclusively  used,  we  have  simply  to  pare  the  edges  of  the  break, 
and  then  get  the  parts  in  apposition  as  best  we  can.  Herein  con 
sists  the  difficulty  of  such  operations;  and  the  tact  and  knowledge  of 
the  surgeon  will  prove  his  best  guides.  If  the  breaks  are  in  the 
soft  palate,  any  resistance  that  may  be  met  with  is  to  be  overcome 
precisely  as  we  would  overcome  it  in  staphyloraphy:  let  the  sur- 
geon consider  what  muscle  or  muscles  oppose  him,  and  divide  them 
as  before  suggested  ;  or,  if  myotomy  seems  scarcely  necessary,  he 


*  These  manipulations  were  first  practiced  and  described  l»y  mo  in  1801. 


650  ORAL  DISEASES  AND  SURGERY. 

can  in  all  probability  accomplish  his  purpose  by  making  lateral  slits 
through  the  raucous  membrane  alone,  or  otherwise  he  may  go  a 
little  deeper,  making  a  kind  of  semi-myotomy. 

If  the  break  is  small,  one  ligature  will  perhaps  be  all  that  is  neces- 
sary to  secure  the  approximation  of  the  pared  edges;  this  suture 
is  to  be  made  and  fixed  precisely  as  in  the  previous  operation  If 
more  than  one  suture  seems  indicated,  of  course,  two,  three,  or  more 
are  to  be  employed. 

Defects  in  the  hard  palate  are  also  amenable  to  surgical  skill : 
they  may  be  remedied  by  the  use  of  the  knife  and  stimulating  local 
applications,  or,  if  these  fail,  an  artificial  palate,  properly  constructed, 
will  so  admirably  supply  the  deficiency  that  the  patient  is  rendered 
almost  as  well  oif  as  his  fellows. 

Using  the  knife  alone,  most  successful  results  are  frequently  at- 
tained by  first  paring  the  edges  of  the  break  and  afterward  dis- 
secting the  parts  freely  from  the  bone.  This  mode  of  operating  is 
admirably  suited  to  such  hard  palates  as  have  a  thick,  soft,  mucous 
membrane.  By  such  a  mode  of  operating,  and  with  such  a  mucous 
membrane,  quite  wide  chasms  may  be  easily  spanned. 

With  mucous  membrane  of  this  character,  plastic  operations  will 
be  found  to  answer  very  well.  It  is  quite  easy  to  get  a  flap  without 
disturbing  the  periosteum,  and  such  a  flap  may  be  twisted  on  its 
pedicel  without  any  special  interference  with  its  function.  The 
pedicel,  however,  should  be  as  wide  as  possible,  remembering  that 
the  circulation  pertains  to  the  basement  membrane  alone.  An" ob- 
jection, however,  to  such  operations  in  the  mouth  is  the  difficulty 
that  attends  the  fixing  of  the  flap  in  its  new  place. 

The  next  mode  of  relieving  these  defects  that  may  be  alluded  to 
is  that  originally  suggested  by  Dieffenbach.  This  surgeon  com- 
mends the  penciling  of  the  edges  of  the  break  with  tincture  of  can- 
tharides,  hoping  thereby  to  excite  granulation  to  an  extent  that  shall 
fill  up  the  cleft. 

Now,  while  this  does  very  well  for  small  holes,  it  seldom  succeeds 
with  the  larger.  The  granulations,  having  nothing  to  support  them, 
break  down  before  connecting  in  the  middle. 

This  defect  in  the  treatment  can  be  remedied,  and  success  almost 
warranted,  by  the  following  modification  :  make  a  simple  obturator 
or  artificial  palate ;  the  mode  of  doing  which  is  described  in  the^ 
following  chapter.  After  fitting  this  so  as  to  cover  accurately  every 
portion  of  the  hard  palate,  it  may  be  removed,  and  the  cleft  pared ; 
next  touch  the  parts  with  cantharides  or  tinctm*e  of  iodine — the  latter 


PALATINE  DEFECTS  AND    THEIR    TREATMENT.     G51 

I  prefer.  The  plate  is  now  to  be  replaced,  and  will  be  found  to  act 
most  completely  as  a  support  to  the  granulations  which  will  be 
formed.  The  process  of  freshening  the  edges  is,  of  course,  to  be  fre- 
quently repeated ;  but  after  the  first  paring  the  cuts  may  be  made 
from  the  circle  on,  and  not  around,  the  cavity. 

The  next  class  of  palatine  defects  which  claim  our  attention  are 
such  as  require  for  their  relief  a  surgico-mechanical  treatment.  This 
brings  us  to  the  subject  of  the  Obturator, — an  instrument  whose 
style,  form,  and  manufacture  are  of  the  same  interest  to  the  surgeon 
as  are  those  of  the  Pessary  to  the  obstetrician. 


I 


CHAPTER    XL  I. 


OBTURATORS. 


The  instrument,  or  plate,  called  an  obturator,  gets  its  name  from 
the  Latin  verb  ohturo,  and  signifies  a  something  that  shall  close 
or  stop  up  an  entrance  or  break.  Thus,  after  the  operation  of  tre- 
phining, it  is  not  uncommon  to  shield  the  exposed  brain  against  risk  I 
of  accident  by  fitting  a  silver  plate  over  the  site  of  the  removed  bone ; 
and  this  shield  is,  to  all  intents  and  purposes,  an  obturator ;  it  closes 
the  break  in  the  continuity. 

In  the  treatment  of  palatine  defects,  obturators  may  be  employed  j 
with  the  greatest  success ;  the  range  of  their  application  is  really  I 
wonderful.  I  have  seen  one  case,  at  least,  where  the  whole  side  of 
a  face  has  been  so  completely  restored  through  such  instrumentality,  , 
that  a  passing  observer  would  scarcely,  I  think,  have  remarked  any-  I 
thing  amiss  with  the  wearer. 

In  the  consideration  of  the  more  strictly  surgical  treatment  of  pala- 
tine defects,  we  studied  the  operations  which  suggested  themselves 
as  being  the  most  effective  and  promising.  It  is  not,  however,  as 
we  will  find,  every  patient  who  is  willing  to  submit  to  an  operation; 
and  it  is  not,  on  the  other  hand,  as  we  are  prepared  to  understand, 
every  case  that  is  fit  to  be  operated  upon.  To  leave  either  class  of 
persons  to  their  fate  would  be  as  cruel  as  it  would  be  unnecessary  ; 
it  is  here,  therefore,  we  may  so  happily  resort  to  the  means  known 
as  the  surgico-mechanical. 

As  obturators  are  to  fulfill  various  indications,  so,  of  course,  do 
the}"  vary  in  form,  style,  and  method  of  manufacture.  The  simplest 
obturator  is  one  made  to  cover  a  break,  more  or  less  extensive, 
in  the  hard  palate  proper, — that  is,  a  break  which  does  not  impli- 
cate either  the  alveolar  borders  or  the  soft  palate.  Such  an  obtu- 
rator holds  the  same  relative  position  to  obturators  in  general  that 
the  Physick-Dessault  apparatus  holds  to  all  apparatus  for  thigh-frac- 
tures. Both  may  be  termed  principals,  and  all  variations  are  but 
modifications  of  these  principals.  Thus,  if  we  appeciate  the  style, 
indications  met,  and  mode  of  manufacture  of  a  simple  obturator,  we 
(  652  ) 


OBTURATORS. 


653 


understand  fully  the  genius  of  the  instrument,  and  are  thus  enabled 
so  to  appreciate  the  mechanism  of  the  piece  that  we  will  be  prepared 
to  diminish  or  enlarge  its  capacity  jwo  re  nata. 

A  patient  presents  himself  to  us  suffering  under  a  deficiency  in  the 
hard  palate.  We  examine  the  case,  and  find  the  walls  of  the  break 
so  heavily  and  solidly  indurated  that  we  perceive  at  once  that  any 
attempt  to  pare  and  bring  the  parts  together  would  be  futile.  Palato- 
plasty at  once,  and  naturally,  suggests  itself,  but  observation  of  the 
surrounding  parts  convinces  us  that  the  risks  are  too  great  for  the 
good  promised.  Such  is  a  case  that  not  unfrcquently  offers  itself  to  the 
surgeon's  judgment.  Dieffenbach,  whose  name  is  so  honorably  asso- 
ciated with  oral  surgery,  evidently  found  himself  much  embarrassed 
with  just  such  cases — cases  which  I  would  here  present  as  the  easiest 
of  remedy  by  use  of  the  obturator.  It  was  Dieffenbach,  it  will  be 
remembered,  who  suggested  the  stud  of  india-rubber.  Two  pieces 
of  rubber  the  thickness  of  pasteboard  were  cut  three  or  four  times 
larger  than  the  opening  to  be  closed,  and  between  these  was  placed 
a  small  round  piece ;  the  whole  was  then  securely  fastened  together 
by  means  of  waxed  thread ;  one  of  these  pieces  was  intended  to  rest 
on  the  posterior  and  the  other  on  the  anterior  surface  of  the  opening; 
the  small  middle  piece  was  for  the  intermediate  space. 

A  moment's  reflection  will  exhibit  the  inconveniences  as  well 
as  the  more  striking  faults  of  such  an  appliance.  The  rubber,  unless 
it  was  vulcanized  (and  to  be  so  applied,  it  could  not  be  vulcanized), 
would  soon  become  very  offensive.  It  would  act  as  a  continual 
source  of  irritation,  and  particularly  so  far  as  the  posterior  base  of 
the  cleft  is  concerned.  The  center  piece,  which,  to  hold  the  parts 
with  any  degree  of  steadiness,  would  have  to  fit  the  opening  with 
some  degree  of  accuracy,  would,  because  of  the  presence  of  moisture 
and  heat,  soon  expand,  thus  enlarging  the  canal.  It  would  be  very 
inconvenient  to  remove  for  the  purpose  of  cleansing,  which  cleans- 
ing it  would  certainly  demand  daily. 

A  case  amply  illustrative  of  the  inefficiency  of  this  mode  of 
treating  palatine  defects,  and,  indeed,  of  the  absolute  harm  resulting 
from  it,  is  recorded  by  Dr.  J.  H.  McQuillen,  in  the  Denial  Cosmos. 
The  patient,  who  had  an  opening  in  the  palate,  the  result  of  syphilis, 
was  treated  by  Dr.  Xeall,  who  employed,  in  the  first  instance,  india- 
rubber  as  a  substance  from  which  to  construct  an  obturator.  This 
was  cut  somewhat  in  a  button  shape,  being  large  above  and  l)elow, 
and  contracted  in  the  center,  thus  constituting  an  apparatus  which 
was  retained  in  position  by  resting  on  the  floor  of  the  nares,  sur- 


654  ORAL   DISEASES  AND   SURGERY. 

rounding  the  orifice.  After  it  had  been  worn  a  week  or  two,  the 
patient  returned,  when  it  w^as  found  quite  loose  and  the  orifice  some- 
what enlarged,  the  rubber  having  acted  as  a  source  of  irritation  and 
induced  absorption.  Another  apparatus  was  formed  from  the  same 
material,  and,  after  being  worn  a  week  or  so,  the  orifice  was  found 
much  larger  than  at  the  previous  meeting.  The  rubber  was  also 
found  considerably  affected  by  the  fluids  of  the  mouth.  Satisfied 
that  it  would  not  answer  the  purpose  intended,  this  material  was 
abandoned,  and  a  simple  obturator  of  silver  was  constructed,  cover- 
ing the  orifice  and  roof  of  the  mouth.  This  was  found  to  fulfill  every 
indication. 

There  is  another,  a  somewhat  domestic  treatment  for  these  defects, 
which  I  may  here  allude  to.  This  consists  in  stuffing  the  break  with 
cotton  or  wool.  The  cotton  not  unfrequently  escapes  into  the  throat, 
or,  passing  into  the  nares,  it  has  sometimes  produced  ozasna  by  lodg- 
ing among  the  turbinated  bones :  quite  extensive  necrosis  of  these 
bones  has  also  been  provoked  in  this  way.  The  practice  is  not 
without  its  danger. 

A  case  of  a  different  class,  yet  belonging  to  the  same  category  so 
far  as  treatment  is  concerned,  invites,  in  connection  with  the  consider- 
ation of  simple  obturators,  a  moment's  attention.  This  is  the  existence 
of  a  cleft  or  break  associated  with  subacute  or  chronic  disease — the 
cases  to  which  we  allude  as  not  being  fit  for  operation. 

Some  time  since,  Mr. ,  a  French  teacher  of  this  city,  had  ne- 
crosis of  the  palatine  arch,  the  result  of  venereal  disease;  the  se- 
questrum that  came  away  was  quite  large,  producing  a  break  in  the 
continuity  of  the  hard  palate  at  least  an  inch  in  diameter,  of  course 
freely  exposing  the  nares.  The  result  was,  as  might  be  anticipated, 
that  his  vocation  as  a  teacher  had  at  once  to  be  relinquished. 

I  saw  this  case,  in  consultation  with  the  attending  surgeon,  about 
a  month  after  the  patient  had  resigned  a  situation  which  he  held  in 
one  of  our  principal  private  schools,  and  upon  which,  up  to  this 
time,  he  had  mainly  depended  for  his  income.  The  necessities  of 
the  man  w^ere,  of  course,  immediate,  and  any  operation  for  the  resto- 
ration of  his  speech  was  out  of  the  question.  I  had  the  happiness 
of  relieving  him  of  his  trouble  so  perfectly  after  three  days,  by  the 
use  of  an  obturator,  that  every  time  he  has  since  met  me  he  has 
laughingly  assured  me  that  he  speaks  much  better  English  than 
before  his  accident.  It  is  certainly  true  that  he  speaks  quite  as 
well. 

The  obturator  for  these  cases  consists  simply  of  a  metal  plate 


OBTURATORS.  555 

that  shall  fit  accurately  eveiy  part  of  the  hard  palate,  tiie  regu- 
larity of  the  arch  to  be  restored  by  carrying  the  plate  over  the  cleft 
or  break.  Such  a  plate  should  fit  with  the  greatest  nicety,  and  is  to 
be  held  in  place  either  by  bands  placed  around  certain  of  the  teeth,  or 
otherwise  by  means  of  atmospheric  pressure.  The  first  plan  of  fast- 
ening the  piece  should  be  employed  when  disease  is  associated  with 
the  cleft.  The  latter  is  well  adapted  when  the  break  is  not  too  large, 
and  where  all  disease  has  long  passed  away.  To  make  such  an  ob- 
turator, first  take  an  ordinary  impression  cup,  such  as  is  employed 
in  taking  casts  of  the  mouth.  This  cup  is  filled  with  ordinary  bees- 
wax, softened  before  the  fire  to  the  consistency  of  dough.  Thus  pre- 
pared, the  operator  takes  his  position  behind  the  patient,  as  recom- 
mended in  the  operation  of  staphyloraphy.  The  cup  is  now  to  be 
introduced  carefully  into  the  mouth,  and  carried  just  so  far  back  as 
will  allow  of  the  teeth  being  included  within  the  arch  or  rim  of  the 
cup.  This  accomplished,  cup  and  wax,  in  a  body,  are  to  be  pressed 
firmly  up  into  the  roof  of  the  mouth  and  around  the  neck  of  the 
teeth  and  alveolar  border.  The  patient  holding  the  mouth  very 
wide  open,  the  mass  is  to  be  removed  even  more  carefully  than  it  was 
inserted.  This  manipulation,  if  properly  executed,  gives  us  the 
exact  impression  of  the  mouth.  The  next  step  is  to  make  a  model. 
To  do  this,  we  take  the  impression  we  have  just  obtained,  and,  sur- 
rounding it  with  a  rim  of  paper,  the  rim  to  be,  say,  one  and  a  half 
inches  in  height,  we  stir  into  water  the  common  calcined  phistfr — 
sulphate  of  lime — until  we  have  a  very  thick,  creamy  paste.  This 
paste  is  poured  into  the  impression,  and  should  be  enough  to  fill 
from  the  wax,  which  lies  at  the  bottom,  up  to  the  top  of  the  rim. 
The  model  thus  made  is  not  to  be  disturbed  for  three  or  four  hours ; 
it  must  have  time  to  set. 

The  next  step  in  the  operation  is  to  remove,  from  about  the  plaster 
cast  we  have  just  made,  the  paper  and  wax.  This  is  accomplished, 
first,  by  heating  gently  the  cup  in  which  the  wax  lies,  which  per- 
mits of  its  easy  removal ;  and  next  carefully  trimming  from  about 
the  necks  of  the  teeth,  by  means  of  a  knife-blade  kept  constantly 
warm,  the  wax  which  so  closely  surrounds  and  imljcds  them;  in 
this  way  the  wax  may  all  be  safely  taken  away.  The  paper  is,  of 
course,  simply  to  be  torn  away,  and  this  is  done  before  removing 
either  cup  or  wax.  Comparing  the  face  of  the  model  thus  made 
with  the  mouth  from  which  the  impression  was  taken,  we  shall  find 
we  have  its  counterpart  to  the  minutest  particular. 

As  the  model  contains  the  break  in  the  urch,  and  it  is  our  inten- 


656  OBAL  DISEASES  AND   Si^EGERY. 

tion  to  restore  this  arch  to  its  original  and  natural  contour,  so  is  it 
at  this  step  in  the  procedure  that  we  can  best  secure  our  object. 
This,  I  think,  is  most  easily  done  by  taking  a  little  ball  of  warm  wax, 
and  filling  with  it  the  hole  or  break  in  the  model.  The  natural  con- 
cavity of  the  arch  is  in  this  way  restored.  Of  course  this  is  not  at 
all  difficult,  nor  is  there  any  guess-work  about  it,  as  we  hare  the  in- 
clinations of  all  the  surrounding  parts  to  guide  us,  and  all  we  have 
to  do  is  simply  to  model  this  wax  to  the  proi)er  curve. 

The  cast  is  finished  by  beveling.the  portion  which  rested  against 
the  paper  ;  this  beveling  to  be  so  done  that  the  greatest  diameter  of 
the  model  shall  be  its  base. 

This  completes  the  model  to  which  the  obturator  is  to  be  made. 

The  next  step  is  the  preparation  of  dies.  These  are  to  be  made, 
one  of  zinc,  the  other  of  lead ;  and  the  process  of  getting  up  such 
casts  is  precisely  the  same  as  that  adopted  by  the  dentist  or  the 
moulder. 

Procure  a  circle  of  tin:  a  common  tin  cup,  with  the  bottom  broken 
out,  answers  the  purpose  well  enough.  Lay  the  model  you  have  pre- 
pared upon  the  table,  the  palate  face  looking  up.  Now  place  the 
circle  of  tin  over  it,  and  with  some  moulder's  sand,  veiy  fine,  which 
you  have  previously  moistened  and  tempered,  cover  in  the  model, 
packing  and  filling  the  circle  completely.  Now  turn  the  circle  or 
cup  so  that  the  base  of  the  cast  looks  up.  Next  a  penknife-blade  or 
small  gimlet  is  to  be  inserted  into  the  plaster,  and  by  striking  it 
several  light  taps  the  cast  will  be  loosened.  It  is  now  to  be  lifted 
from  the  sand  by  means  of  the  knife-blade.  Thus  we  have  a  mould 
for  a  metal  casting.  The  next  step  is  the  making  of  such  a  cast. 
To  do  this  we  have  only  to  melt  one  or  two  pounds  of  common 
zinc,  in  any  convenient  vessel,  and  pour  it  slowly  into  the  mould. 
This  done,  let  the  whole  remain  undisturbed  until  completely 
cold. 

Tims,  it  is  seen,  we  have  prepared,  with  little  or  no  labor,  a  cor- 
rect model  of  the  mouth  in  metal.  It  is  to  this  zinc  model  we  are 
to  fit  and  adapt  our  obturator.  Now,  this  latter  process  is  easy  or 
difficult,  according  as  one  goes  about  it.  One  method  is  to  take 
hammer,  files,  and  pliers,  and  cut,  file,  and  mallet,  until  the  adapta- 
tion is  secured.  Such  a  task  is  almost  as  hard  as  was  the  cleaning 
of  the  Augean  stables ;  besides,  it  is  next  to  an  impossibility  to 
accomplish  it  properly.  A  second  plan,  and  one  which  is  as  easy, 
simple,  and  interesting  as  the  other  is  difficult,  perplexing,  and 
annoying,  consists    in   making  a  counter  model  in   lead,  between 


OBTURATORS.  657 

which  and  the  model,  or  male  cast,  the  plate  or  obturator  is  to  be 
struck  up.     This  counter  model  is  very  easily  made,  as  follows: 

Take  the  zinc  cast  and  lay  it  upon  the  table,  with  the  face  or  pal- 
atine surface  looking  up ;  lay  over  it  the  cup  or  circle,  precisely  as 
in  the  case  of  the  plaster  model.  Now,  with  the  sand  moistened  as 
before,  fill  up  the  cup  covering  in  the  cast — packing  the  sand  as  solid 
as  possible.  Next,  without  disturbing  the  cup  as  it  rests  upon  the 
table,  take  a  knife  and  dig  away  the  sand  until  you  expose  the  face 
of  the  cast.  You  are  now  prepared  to  make  the  counter  model. 
Take  a  vessel,  not  the  one  in  which  you  melted  th(!  zinc,  and  place 
in  it  two  or  more  pounds  of  lead;  when  melted,  pour  this  over  the 
face  of  the  zinc  cast,  filling  up  to  the  very  top  the  hole  which  you 
have  dug  out  in  the  sand.  When  the  lead  has  become  cool,  take  the 
castings  from  the  sand,  and,  with  a  hammer,  the  two  can  be  easily 
knocked  apart. 

To  make  the  obturator,  by  means  of  these  dies,  we  next  proceed 
as  follows :  a  piece  of  thin  sheet-lead  is  forced  with  the  fingers  over 
the  face  of  the  zinc  cast;  with  a  sharp  and  delicate-bladed  knife  this 
lead  is  cut  so  as  to  cover  accuratel}^  the  hard  palate,  being  even  fes- 
tooned so  as  to  adapt  itself  accurately  about  the  necks  of  all  the 
teeth.  This  palate  of  lead  being  thus  nicely  and  correctly  fitted  to 
the  parts,  it  is  taken  off  the  casts  and  carefully  spread  out.  Next  it 
is  laid  on  a  piece  of  gold  or  silver  plate,  and  the  outlines  distinctly 
marked  with  cutting  forceps;  the  shape  of  the  arch,  as  marked 
from  the  lead,  is  then  cut  out  from  this  second  piece  of  metal.  The 
next  step  is  the  process  of  annealing,  or  softening  the  metal,  so  that 
it  shall  be  as  malleable  as  possible.  This  consists  in  subjecting  it  to 
a  red  heat,  which  may  be  done  in  any  convenient  manner.  The 
dentist  lays  the  piece  on  charcoal,  and  throws  over  it,  by  means  of 
a  blow-pipe,  the  flame  from  his  alcohol  soldering-lamp.  This  does  it 
very  nicely. 

It  is  next  to  be  taken  up,  and  bent  with  the  pliers  so  as  to  fit 
the  cast  tolerably;  it  is  not,  however,  at  all  necessary,  in  this 
procedure,  to  give  one's  self  much  trouble.  Next  take  up  the  coun- 
ter model,  and  lay  it  carefully  over  the  zinc— the  plate  being  be- 
tween the  two.  With  the  hammer  the  casts  are  now  to  be  driven 
together.  In  this  step  of  the  operation  it  is  rather  desirable  that 
we  should  feel  our  way,— that  is,  hit  the  models  a  few  slight  taps, 
and  then,  taking  them  apart,  see  if  the  plate  is  going  as  we  wnnt 
it.  If  all  is  right,  the  casts  may  be  driven  into  each  other  w.tl. 
all  reasonable  force.     If,  on  the  contrary,  the  plate  is  not  takuig 

42 


668  ORAL   DISEASES  AND   SURGERY. 

a  proper  direction,  it  must  be  so  inclined  by  means  of  the  pliers. 
To  complete  the  finish  of  the  plate  itself,  it  may,  perhaps,  require 
that  the  festoons,  which  are  to  embrace  the  necks  of  the  teeth,  be 
cleanly  cut  out  by  means  of  the  ordinary  round  file. 

Thus  we  have  our  obturator  completed.  If  we  place  it  in  the 
mouth,  we  will  see  that  we  have  restored  the  arch,  by  our  con- 
trivance, to  its  original  condition,  at  least  so  far  as  the  purposes  of 
speech  and  mastication  are  concerned. 

Nothing  now  remains  but  to  secure  the  piece  firmly  to  its  place. 
And  this  brings  us  to  the  consideration  of  modifications  of  the 
instrument. 

If  a  patient,  for  whom  we  had  made  such  an  obturator  as  that 
the  manufacture  of  which  I  have  just  described,  had  certain  good 
sound  teeth,  we  might  proceed  to  fix  the  piece  in  the  mouth  as  fol- 
lows: going  back  to  the  plaster  model,  we  would  fit  around  such 
teeth  as  might  seem  to  us  best,  delicate  bands  of  metal — gold  should 
always  be  preferred ;  these  bands  should  fit  the  teeth  with  great 
accuracy,  and  are  to  be  fixed  to  their  places  while  the  obturator  is 
lying  on  the  model.  Take  next  a  particle  of  wax,  and  stick  the 
plate  and  bands  together.  Now  carefully  lift  all  from  the  model, 
and  set  in  plaster.  This  last  manipulation  is  accomplished  by 
laying  the  piece  on  charcoal,  and  pouring  over  all,  the  wax  alone 
excepted,  the  creamy  plaster,  before  alluded  to.  When  this  plaster 
sets,  the  wax  is  taken  away,  and  there  is  exposed  a  small  portion, 
both  of  obturator  and  bands.  These  parts  are  to  be  soldered  to- 
gether. 

This  last  process  fits  the  piece  for  the  mouth.  In  placing  it  in 
position,  we  have  only  to  slip  the  bands  over  the  teeth,  and  we  will 
find  that  it  is  held  with  all  security. 

Another  plan  of  securing  the  apparatus  to  the  mouth  is  by  means 
of  atmospheric  pressure.  To  accomplish  this,  a  cavity  is  to  be  made 
in  the  piece.  This  is  done  by  placing  on  the  plaster  model,  before: 
making  the  castings  from  it,  a  piece  of  wax ;  its  shape  may  repre-' 
sent,  in  diameter  and  thickness,  the  ordinary  half  dime.  Or  per- 
haps we  cannot  find  a  surface  on  the  arch  for  a  suction  of  such  size 
and  shape  ;  if  so,  it  may  be  lessened,  or  the  shape  may  be  modified 
so  as  to  suit  any  case.  What  we  want  is  a  cavity  in  the  plate  ;  the 
size  and  location  are  not  of  so  much  consequence.  Such  a  piece  of 
wax  will,  of  course,  be  represented  by  zinc  in  the  casting,  and  by  a 
depression  in  the  counter  cast.  In  forcing  the  plate  between  the 
dies,  the  portion  represented  by  the  wax  is  thrown  up;  thus,  when 


I 


OBTURATORS. 


659 


the  plate  is  in  the  mouth,  a  cavity  is  formed.  The  obturator  is  held, 
in  this  case,  by  making  an  air-pump,  as  it  were,  of  the  tongue,  au(l 
sucking  the  air  from  the  cavity.  I  have  seen  obturators,  thus  de- 
pendent on  atmospheric  pressure  for  fixedness,  held  so  tightly  that  it 
required  quite  an  amount  of  force  for  their  r<iraoval.  The  principle 
is  the  same  as  that  employed  for  holding  artificial  teeth  in  place. 
The  whole  modus  operandi  will  be  perfectly  understood  at  a  glance 
by  looking  at  any  set  of  teeth  made  for  the  superior  jaw. 

Another  modification  of  the  obturator  is  that  in  which  the  piece  is 
held  to  its  place  by  a  bulb  or  rim,  which  passes  into  the  cavity  of 
the  break.  This  adapts  the  instrument  to  such  cases  as  have  neither 
teeth  nor  site  for  suction,  where,  for  instance,  disease  has  destroyed 
the  whole  of  the  hard  palate,  leaving  alone,  as  boundaries  of  the 
cleft,  the  alveolar  processes  and  soft  palate.  Such  an  obturator, 
and  the  character  of  cleft  for  which  it  is  adapted,  are  happilv  and 
truthfully  exhibited  in  the  accompanying  drawings.  Fig.  105  repre- 
sents the  mouth.  Fig.  106  the  obturator.  This  case,  together  with 
others  which  represent  various  modifications  of  the  apparatus,  are 
from  life,  having  occurred  in  the  practice  of  prominent  dentists  of 
this  city.  The  models,  with  an  accompanying  history  of  the  cases, 
were  presented  to  the  Pennsylvania  Association  of  Dentists,  at  a 
meeting  held  by  that  Society,  October  9th,  I860.* 

"  The  first  case,  as  seen  in  Fig.  105,  from  the  practice  of  Dr.  McGrath 
&  Son,  was  that  of  a  female  over  fifty  years  of  age.  In  this  instance 
the  fissure  was  confined  to  the  hard  palate,  and  was  undoubtedly 
the  result  of  syphilis.  Of  the  history  of  this  case,  all  that  could  l)e 
obtained  was  such  as  was  derived  from  answers  to  indirect  ques- 
tions which  were  put  to  her.  They  learned  that  the  defect  was  the 
result  of  a  disease  which  commenced  as  sore-throat  and  continued 
its  ravages  for  over  three  years  before  it  was  arrested  ;  this,  together 
with  the  appearance  of  the  pharynx  and  uvula, — they  being  covered 
with  cicatrices,  the  result  of  old  ulcers, — ^left  them  without  any  doubt 
as  to  the  true  nature  of  the  complaint.  The  parts  which  had  been 
destroyed  during  the  progress  of  the  disease  were  the  palate-bones 
and  the  palatine  processes  of  the  superior  maxillaries  (making  an 
opening  into  the  nose  nearly  two  inches  in  length  and  one  inch  in 
breadth),  the  turbinated  bones  (with  the  exception  of  the  middle  one 
on  the  left  side,  which  is  represented  in  the  cut  as  projecting  from 
the  side  of  the  cavity)  and  the  vomer,  producing  an  enormous  irregu- 


*  Keport  by  Geo.  T.  Barker,  D.D.S. 


600 


ORAL  DISEASES  AND  SURGERY. 


larly  shaped  cavity,  extending  as  high  up  as  the  nasal  bones,  which 
latter,  however,  bore  no  traces  of  ever  having  been  affected  by  the 


Fig.  105. 


disease.  The  patient,  in  order  to  prevent  the  passage  of  the  food 
into  the  cavity  during  mastication,  had  been  in  the  habit  of  filling 
the  opening  with  a  fold  of  muslin,  which  answered  the  purpose  to 
a  certain  extent ;  the  velum  was  entire  ;  the  patient  had  also  lost 
all  the  teeth  of  the  upper  jaw. 

"  The  kind  of  obturator  employed  in  this  case  was  simple  and 
uncomplicated  in  its  mechanism,  Fig.  106.  A  plate  was  made  to 
fit  accurately  to  the  alveolar  ridge,  extending  about  one-eighth  of 
an  inch  beyond  the  posterior  margin  of  the  opening;  also  passing  in 
to  a  distance  of  nearly  an  inch,  and  fitting  as  closely  as  possible  to 
the  anterior  and  lateral  sides  of  the  cavity.  The  object  of  this  latter 
arrangement  was  to  render  the  plate  firm  in  its  position.  From  the 
posterior  margin  of  the  opening,  and  extending  forward  about  half 
the  length  of  the  alveolar  ridge,  was  a  fold  of  mucous  membrane 
projecting  inward  and  upward,  over  this  fold ;  that  portion  of  the 
plate  which  was  opposite  to  it  was  bent.  This,  together  with  the 
suction  obtained  by  the  plate  fitting  closely  to  the  alveolar  ridge, 


OBTUBATORS.  ,3g^ 

enabled  the  wearer  to  keep  it  in  its  place.  The  openin.^  was  then 
covered,  by  soldering  to  this  a  second  piece  of  plate,  so  fashioned  as 
to  represent  as  nearly  as  possible  the  form  of  the  lost  palate  The 
object  in  not  extending  the  plate  into  the  cavity  on  the  posterior 
edge  of  the  opening  was  to  prevent  a  lodgment  for  the  nasal  secre- 
tions, which  by  their  accumulation  would  prove  offensive  to  th(> 
patient.  The  artificial  teeth  were  then  fastened  in  their  proper 
position,  and  the  apparatus  was  complete.  This  obturator  the  pa- 
tient has  been  wearing  for  about  three  months;  it  remains  in  place 


Fig.  106. 


and  fulfills  the  office  of  mastication  as  well  as  any  ordinary  suction 
plate  in  a  mouth  where  no  defect  of  the  palate  exists. 

"The  second  case.  Fig.  107,  was  also  that  of  a  female,  but  the 
fissure  was  confined  to  the  soft  palate.  This,  as  in  the  former  case, 
Avas  the  result  of  syphilis.  The  fissure  extended  from  the  posterior 
opening  of  the  nares  through  the  velum  to  the  palate-bones,  and  was 
nearh^  an  inch  in  breadth.  The  uvula  was  entirely  gone,  as  well  as 
the  lateral  half  arches,  and  along  with  them  the  palato-pharyngei 
and  constrictors  isthmi  faucium  muscles.  In  this  case  deglutition 
was  impaired  to  a  great  extent ;  the  food  would  pass  into  the  nares, 
and  the  fluids  would  also  pass  into  the  nasal  cavity  and  out  through 
their  anterior  openings.  The  disease  had  not  confined  itself  to  the 
palate,  but,  extending  to  the  nasal  organs,  had  completely  destroyed 
their  internal  structure,  as  well  as  a  portion  of  the  nasal  bone,  to 
such  an  extent  as  to  materially  change  the  external  shape  of  that 
organ.     The  obturator.  Fig.  108,  constructed  for  this  case,  was  of 


662 


ORAL  DISEASES  AND   SURGERY. 


one  piece,  and  made  to  cover  the  hard  palate  completely,  extending 
from  the  central  incisors  to  the  posterior  wall  of  the  pharynx,  and 


Fig.  107. 


passing  a  short  distance  beyond  the  edges  of  the  opening  on  each 
side.  The  plate  was  made  to  press  firmly  against  that  portion  of 
the  soft  palate  which  remained,  yet  not  so  firm  as  to  be  the  cause  of 
irritation,  the  edges  of  the  plate  being  slightly  bent  downward  for 
the  same  reason ;  the  object  being  to  prevent  the  possibility  of  the 
soft  parts  being  drawn  above  the  palate,  which  would  afford  a  com- 
munication with  the  nares.  The  posterior  edge  of  the  obturator  Avas 
bent  downward  at  a  right  angle  with  the  body  of  the  palate,  and 
curved  so  as  to  form  with  the  posterior  wall  of  the  pharynx  an  oval 
opening  sufficiently  large  to  permit  the  patient  to  breathe  freely 
through  the  nostrils.  In  the  act  of  deglutition,  the  muscles  would 
contract  and  press  against  this  portion  of  the  plate,  thereby  cutting 
off  the  communication  with  the  nares.  To  this  plate  were  attached 
three  artificial  teeth, — two  lateral  incisors  and  one  molar, — the  whole 
being  retained  in  position  by  means  of  clasps  around  the  teeth. 


OBTURATORS. 


663 


"This  obturator  the  patient  has  been  wearing  a  little  over  two 
months,  and,  like  the  former  one,  has  proved  successful,  deglutition 
being  restored,  and  the  speech  considerably  improved." 


Fig.  108. 


Dr.  T.  L.  Buckingham,  Professor  of  Chemistry  in  the  Pennsyl- 
vania College  of  Dental  Surgery,  presented  the  following  cases: 

"The  first  ease,"  he  said,  "he  had  anything  to  do  with  was  that 
of  a  gentleman  who  had  an  opening  through  the  hard  palate,  in  the 
center  of  the  arch,  about  as  large  as  a  ten-cent  piece.  This  gentle- 
man had  worn  an  obturator  with  a  sponge  attached  to  it,  made  in 
the  following  manner :  a  plate  was  struck  up  to  fit  the  roof  of  the 
mouth,  and  a  piece  of  sponge  was  sewed  upon  the  palatine  surface 
to  fill  the  opening,  and  to  hold  the  plate  in  its  place.  Some  of  the 
objections  to  this  obturator  were  that  the  opening  became  enlarged 
from  the  absorption  occasioned  by  the  pressure  of  the  sponge  upon 
the  sides  of  the  cavity;  it  would  also  become  very  offensive,  and  re- 
quire frequent  removal.  In  this  case  a  plate  was  struck  up  to  fit 
the  mouth,  and  attached  to  the  teeth  by  means  of  clasps.  This 
simple  appliance  answered  better  than  any  other  that  had  been  made 
for  him. 

"The  second  case  was  a  gentleman  who  had  an  opening  into  the  left 
antrum,  at  the  point  where  the  second  bicuspid  and  the  first  molar  had 
been,  but  on  the  outer  surface  of  the  alveolar  ridge,  or  rather  where 


664 


ORAL  DISEASES  AXD   SUBGERT. 


the  ridge  had  been — for  the  alveolus  was  entirely  absorbed  opposite 
the  opening,  which  was  about  half  an  inch  in  length  by  a  quarter  in 
width.  The  nasal  bones  were  diseased,  which  caused  an  almost 
intolerable  odor. 

"  He  made  for  this  case  a  small  obturator  to  close  the  opening. 
This  was  left  open  at  the  top  to  allow  him  to  place  in  it  a  small  por- 
tion of  chloride  of  lime.  His  intention  was  to  correct,  if  possible, 
the  oflfensive  smell,  but  the  patient  did  not  live  long  enough  to  give 
it  a  fair  trial ;  he  remarked  that  while  any  of  the  chloride  of  lime 
remained  in  the  obturator  there  was  no  unpleasant  smell;  but,  unfor- 
tunately for  the  experiment,  the  gentleman  had  lost  nearly  all  the 
sense  of  smell,  and  therefore  could  not  tell  when  it  had  evaporated. 

"He  made  for  this  case  an  upper  set  of  teeth,  to  which  the  obtu- 
rator was  secured,  it  being  held  in  position,  to  a  great  degree,  by  the 
plate  and  teeth. 

"In  the  two  preceding  cases  the  voice  was  not  altered  when  the 
appliances  were  in  the  mouth. 

"  The  third  case  was  that  of  a  gentleman  who,  on  a  previous  occa- 

TiG.  109. 


sion,  had  a  tumor  removed  which  covered  a  portion  of  the  posterior 
surface  of  the  hard  and  the  anterior  surface  of  the  soft  palate.  The 
surgeon,  on  its  removal,  had  divided  the  velum  and  uvula,  so  that  the 


OBTURATORS. 


665 


case  resembled  a  congenital  deformity.  The  attempt  had  been  made 
twice  to  bring  the  soft  parts  together  again  by  a  surgical  operation, 
which  bad  failed. 

"  Fig.  109  shows  the  appearance  of  the  parts  very  clearly— the 
letters  A  and  B  showing  the  thickened  muscles  as  they  hung  down 
on  the  side  of  the  pharynx. 

"  He  made  for  this  case  an  obtm-ator,  Fig.  110,  the  plate  of  which 


Fig.  110. 


covered  the  whole  of  the  roof  of  the  mouth,  with  a  bulb  attached,  to 
extend  up  into  the  posterior  nares  and  well  back  toward  the  antero- 
posterior walls  of  the  pharynx,  leaving  but  a  small  space  between 
them.  This  obturator  enabled  the  patient  to  eat  and  drink  without 
annoyance ;  without  it  food  would  pass  into  the  nares  and  occasion 
much  inconvenience.  It  also  greatly  assisted  his  voice,  as  many  of 
his  words  could  not  be  understood  when  it  was  not  worn,  but  he 
could  articulate  them  with  great  distinctness  when  it  was  in  place ; 
remarked  that  he  had  been  more  successful  in  restoring  the  voice  in 
this  case  than  in  any  other  he  had  treated,  and  attributed  it  to  the 
fact  that  this  person,  having  once  had  his  voice  perfect,  was  always 
endeavoring  to  speak  as  he  had  formerly  done,  while  in  the  congeni- 
tal cases  they  did  not  try  to  overcome  this  difficulty. 

"  The  fourth  case  was  that'  of  a  lady  who  had  an  opening  in  the 
anterior  part  of  the  hard  palate,  a  little  larger  than  a  ten-cent  piece, 
and  also  a  small  one  exposing  the  left  antrum.  All  the  teeth  in  the 
superior  arch  had  been  removed,  and  absorption  of  the  alveolar  pro- 
cess, opposite  the  smaller  opening,  had  progressed  to  such  an  extent 
as  to  present  at  that  point  a  deep  depression ;  the  remaining  part  of 
the  alveolar  ridge  had  not  been  absorbtnl  more  than  is  usual  where 
the  teeth  have  been  lost. 

"Fig.  Ill  shows  the  appearance  of  the  different  parts — C  repre- 
senting the  smaller  opening,  and  D  the  larger  one;  between  these 
two  points  was  the  depression  referred  to. 


666 


ORAL  DISEASES  AND  SURGERY. 


"  This  lady  had  never  worn  any  mechanical  appliance,  but  had 
been  in  the  habit  of  closing  the  larger  opening  with  loosfe  cotton  or 
pieces  of  linen.  Without  having  it  filled,  she  could  scarcely  be  un- 
derstood when  speaking.  He  made  for  this  case,  first,  a  plain  plate 
to  extend  over  both  the  openings,  but  not  into  them ;  upon  this  plate, 
at  the  point  where  the  process  had  been  absorbed,  he  arranged  wax 
so  as  to  restore  the  alveolar  ridge  to  its  natural  fullness.  By  using 
the  plate  with  the  wax  attached  for  a  mould,  he  was  able  to  obtain 
metallic  dies.  A  second  plate  was  then  made  to  fit  over  that  part 
of  the  first  one  which  was  covered  by  the  wax ;  these  two  plates  were 
then  soldered  together.  The  object  in  forming  a  double  plate  was 
to  fill  up  that  part  where  absorption  had  taken  place,  so  that  the 


Fig.  111. 


plate  when  worn  would  resemble  the  roof  of  the  mouth,  and  not  be 
deeper  on  one  side  than  ou  the  other. 

"  This  obturator  was  very  successful,  the  voice  was  much  im- 
proved, and  she  could  eat  and  drink  as  well  as  persons  ordinarily 
can  who  wear  upper  sets  of  teeth  ;  and,  what  was  more  remarkable, 
she  could  wear  it  without  springs  or  any  assistance  whatever  to 
retain  it  in  position. 

"  He  stated  that  he  hardly  knew  whether  his  fifth  case  should 
come  under  discussion  at  the  present  time  or  not,  as  it  could  hardly 
be  termed  a  palatine  fissure ;  but,  from  its  exceeding  interest,  he 
would  now  present  it. 


OBTURATORS. 


667 


"A  gentleman  was  handling  a  gun  loaded  with  l)uckshot,  when 
it  was  discharged  in  his  hands.  The  gun  being  pointed  toward  his 
head  at  the  time,  the  load  struck  him  at  the  angle  made  by  the  ramus 
and  the  body  of  the  inferior  maxillary  on  the  right  side,  passing  up- 
ward and  outward  on  the  opposite  side  of  the  face.  It  must  have 
been  a  terrible  wound,  and  should,  frorfl  the  representation  given, 
have  caused  almost  instant  death  He,  however,  recovered,  after 
being  confined  to  his  bed  for  more  than  a  year,  and  during  that  time 
he  had  to  be  fed  with  a  spoon.  The  only  way  he  could  eat  or  drink 
was  to  lie  on  his  back  and  let  the  food  run  down  his  throat,  and  it 
was  a  long  time  before  he  found  he  could  swallow. 

"  The  teeth  in  the  upper  jaw  were  all  gone  excoptingthe  left  second 
molar  and  wisdom  tooth  ;  both  antra  were  fully  exposed,  the  re- 
maining roof  of  the  mouth  being  left  almost  flat.  The  lower  jaw- 
bone was  gone  on  the  right  side,  from  the  second  bicuspid  back,  and 
also  the  condyloid  process  ;  but  about  three-quarters  of  an  inch  of 
the  coronoid  remained,  which  was  drawn  in  so  as  to  partially  cover 
the  roof  of  the  mouth.  The  molar  teeth  were  lost  on  the  left  side, 
and  also  all  on  the  right  side  from  the  symphysis.  In  taking  hold 
of  the  lower  jaw  it  could  be  moved  either  backward,  forward,  or 
laterally,  to  a  considerable  distance. 

Fig.  112. 


"  Figs.  112  and  113  show  this  case— the  letters  A  and  B  the  open- 
i  ings  in  the  antrum,  and  C  the  end  of  the  lower  jaw-bone.     The  dis- 


668  ORAL   DISEASES  AND  SURGERY. 

tance  between  the  points  A  and  C,  when  the  mouth  was  closed,  was 
just  two  inches. 


Fig.  113. 


1^     % 


"  This  gentleman  had  been  wearing  a  partial  set  of  upper  teeth 
which  had  been  attached  to  the  molars,  but  the  clasps  of  the  artifi- 
cial teeth  had  loosened  them,  and  it  was  therefore  necessary  to  re- 
place this  piece  of  work  with  a  set  that  could  be  supported  in  some 
other  way. 

"  This  was  the  most  difficult  case  be  had  ever  treated.  One  of 
the  greatest  obstacles  he  encountered  was  the  obtaining  of  a  correct 
impression.  To  accomplish  this,  he  first  filled  the  antra  with  loose 
cotton  to  prevent  the  wax  from  passing  into  them ;  he  then  took  as 
good  a  Avax  impression  as  he  could  of  both  the  upper  and  lower  jaws ; 
from  these  he  made  impression  cups  to  be  used  in  taking  the  plaster 
impressions.  There  was  very  little  difficulty  in  obtaining  an  impres- 
sion of  the  upper  jaw  with  plaster  (the  antra  being  filled  with  cotton 
as  before),  but  it  was  far  more  difficult  to  take  a  good  one  of  the 
lower  jaw.  The  distance  from  the  points  of  the  teeth  down  to  the 
point  marked  C,  as  shown  in  Fig.  112,  was  so  great  that  when  any 
material  was  pressed  down  to  take  the  impression,  it  was  almost 
impossible  to  remove  it  from  the  mouth  without  altering  it  so  much 
as  to  render  it  of  no  value;  after  several  trials  he  succeeded  in  getting 
a  very  good  one  with  plaster.  It  had  to  be  broken  before  its  removal 
from  the  mouth ;  but,  by  carefully  putting  the  pieces  together,  a  good 
plaster  cast  was  obtained. 

"  He  then  made  a  plate  to  extend  over  the  roof  of  the  mouth  and 
cover  both  of  the  cavities  opening  into  the  antra  ;  on  this  plate  he 


OBTURATORS. 


669 


arranged  wax,  briuging  it  clown  as  far  as  the  alveolar  ridge  should 
have  been;  then  made  a  metal  cast  and  struck  another  plate  to  fit 
over  the  first,  soldered  them  together,  and  placed  upon  these  single 
gum  teeth  as  he  would  have  done  had  there  been  no  more  aljsorp- 
tion  than  is  usually  found  in  upper  cases. 

"  There  was  nothing  peculiar  in  the  formation  of  the  lower  case, 
except  that  the  teeth  had  to  be  very  long  on  the  right  side  (for  this 
a  block  was  made),  and  the  plate  was  not  allowed  to  extend  farther 
back  than  to  the  position  once  occupied  by  the  second  bicuspid  tooth. 
The  under  teeth  were  put  in  more  for  the  purpose  of  attaching 
springs  for  the  support  of  the  upper  ones  than  for  use. 

"  He  could  not  say  what  success  had  attended  this  case,  as  the 
gentleman  left  the  city  immediately  upon  their  insertion,  and  he  had 
not  seen  him  since  that  time." 

Other  cases  of  equal  interest  are  found  in  the  report;  but,  as  they 
are  unaccompanied  by  models,  I  omit  them. 

A  material  for  obturators  is  fast  winning  its  way  to  professional 
favor  in  the  article  known  as  Yulcanite.  This  is  the  base  now  so 
extensively  used  in  the  manufacture  of  sets  of  teeth.  Its  merits 
and  demerits  are  widely  discussed  in  all  the  dental  publications  of 
the  day,  and  from  these  journals  everything  pertaining  to  it  may  be 
gleaned.  The  advantages  claimed  for  it  are :  its  cheapness,  its 
lightness,  its  capability  of  being  moulded  into  the  most  irregular 
positions,  and  its  similation  in  color  and  feel  to  the  natural  parts. 
The  objections  are  its  liability  to  decompose  and  become  oS'ensive. 
The  manipulation  of  the  material  is  so  easy  that  the  surgeon  at- 
tempting the  manufacture  from  it  of  surgical  appliances,  would  give 
himself  a  source  of  recreation  rather  than  work.  To  make  an  ob- 
turator from  vulcanite,  you  take  an  impression  of  the  mouth  in  wax 
and  make  from  it  a  plaster  model  precisely  as  before  described. 
Prepared  gutta-percha  is  now  moulded  over  this  model  to  the  form 
required.  Plaster  is  next  run  over  this  first  model,  the  gutta-percha 
plate  being  between.  The  model  and  counter  model  thus  made  are 
separated,  and  the  place  of  the  original  plate  supplied  with  fresh 
vulcanite.  The  models  are  now  put  together,- and  the  vulcanite  be- 
tween subjected  to  pressure.  The  whole  is  then  placed  in  an  ap- 
paratus termed  the  vulcanizer,  and  this  being  filled  with  water  the 
temperature  is  raised  to  about  325  degrees.  When  taken  from  the 
steam-bath  the  plate  is  found  to  be  as  hard  as  bone.  The  last  pro- 
cess consists  in  the  polishing  of  the  piece ;  this  is  a  simple  manipu- 
lation, and  requires  only  one  or  two  files,  a  burnisher,  and  some 
patience. 


670  OFAL   DISEASES  AXD   SURGERYi 

M.  Desirabode,  a  French  surgeon,  proposes  a  palatine  obturator 
for  congenital  fissure  of  the  palate  (see  Harris's  Dictionary),  by  which 
he  thinks  the  sides  of  the  alveolar  border  may  be  so  appi-oximated 
as  to  favor  a  union  of  the  divided  parts.  It  consists  of  a  platina 
plate  fitted  to  the  vault  of  the  palate  and  fastened  to  the  teeth  by 
means  of  three  clasps  soldered  to  each  side,  so  asJ;o  cap  the  canine 
teeth,  the  bicuspid,  and  two  of  the  molar  teeth,  bent  upon  the 
alveolar  border  in  such  a  manner  as  to  maintain  the  whole  pressure. 
After  the  plate  with  these  appendages  has  been  well  adapted,  it  is 
to  be  divided  from  before  backward  along  the  median  line,  and  then 
a  piece  removed  from  either  side  so  that  the  two  edges  may  be  sepa- 
rated about  half  an  inch  from  each  other.  The  two  plates  are  now 
united  by  means  of  a  thick  and  resisting  band  of  caoutchouc,  made 
fast  by  riveting.  The  plates  thus  united  form  a  smaller  obturator 
than  the  plate  before  it  was  divided,  so  that  it  can  only  be  applied 
l)y  putting  the  caoutchouc  on  the  stretch,  which  is  effected  by  means 
of  two  sticks  so  contrived  as  to  force  the  two  plates  asunder.  After 
the  plate  is  properly  adjusted,  these  are  removed,  when,  by  the  con- 
traction of  the  caoutchouc,  the  sides  of  the  alveolar  borders  are 
gradually  approximated. 

This  contrivance  of  Desirabode  looks  very  plausible,  but,  unfortu- 
nately, all  experience  is  against  its  employment. 

In  the  first  place,  to  correct  by  pressure  a  fissure  in  the  hard 
palate,  implies  the  very  earliest  use  of  such  force.  A  child  is  some 
five  or  six  years  old  before  its  first  dentition  is  properly  completed ; 
and  even  at  this  period  one  would  not  dare  to  apply  any  such  ap- 
paratus, because  of  the  physiological  process  of  absorption  which 
has  already  commenced  in  certain  of  the  teeth.  Then  if,  on  the  con- 
trary, he  meant  his  instrument  to  apply  to  a  more  advanced  period, 
he  would  have  to  wait  until  at  least  the'  sixteenth  3'ear,  as  before 
this  age  the  fangs  of  the  molars  are  not  perfected.  The  bones  by 
this  time  have,  as  a  matter  of  course,  become  much  less  amenable 
to  treatment.  And,  again,  even  besides  this,  as  I  know  from  prac- 
tical teachings,  his  apparatus  would  in  less  than  a  week's  time  pro- 
duce such  periosteal  trouble  about  the  alveoli  that  no  human  being 
would,  or  could,  bear  the  continuance  of  the  pressure  ;  or,  even  ad- 
mitting there  should  be  found  a  patient  heroic  enough  to  bear  the 
treatment,  the  apparatus  would  have  its  usefulness  destroyed  in  less 
than  two  weeks  by  the  teeth,  to  which  it  was  attached,  coming 
away.  In  other  words,  the  instrument  is  useless,  because  the  teeth, 
being  the  weaker  and  more  yielding,  would  give  way  first. 


OBTURATOBS. 


G71 


In  Listen  and  Mutter's  Surgery  is  an  engraving  of  an  obturator 
made  to  supply  the  loss  of  both  hard  and  soft  palates.  The  con- 
trivance, which  is  a  simple  plate  such  as  I  have  described,  is  seen 
to  extend  from  the  teeth  back  to  the  fauces.  Attached  to  the  back 
portion  of  the  plate  representing  the  soft  palate,  is  a  metal  pendu- 
lum working  on^a  hinge — this  pendulum  is  much  better  omitted,  for, 
while  it  cannot  possibly  answer  any  useful  purpose,  it  must  cer- 
tainly be  much  in  the  way.  In  making  so  extensive  an  obturator, 
it  must  not  be  forgotten  that  the  part  which  represents  the  soft 
palate  is  to  be  given  the  double  curve  which  is  seen  on  looking  into 
any  healthy  mouth.  To  get  the  impression  for  such  an  obturator 
we  have  only  to  employ  a  deeper  impression  cup. 

Dr.  E.  Wildman,  of  the  Pennsylvania  College  of  Dental  Surgery, 
kindly  furnishes  me  with  a  description  and  cuts  of  a  case,  which,  as 
a  study,  could  scarcely  occupy  too  much  attention.  The  patient  I 
have  myself  seen. 


Fig.  114. — The  Face  without  Nose. 


Fig  lU  will  convey  an  idea  of  the  external  appearance  of  the  pa- 
tient, but  not  fully,  a"s  the  whole  upper  lip  was  cicatrized,  and  the 
left  cheek  depressed  near  the  border  of  the  cavity. 


672 


OBAL  DISEASES  AND  SURGERY. 


"In  May,  1863,  a  young  man,"  says  Dr.  Wildman,  "  aged  26 
years,  presented  himself  for  the  purpose  of  having  an  appliance  made 
to  repair  a  loss  sustained  by  disease.  Upon  removing  the  black  patch 
which  he  wore  upon  his  face,  and  the  cotton  with  which  the  cavity 
was  filled  (without  the  latter  he  could  not  articulate  a  word),  I  found 
that  the  entire  external  nose  was  gone  ;  that  the  nasal  bones,  the  nasal 
processes  of  the  superior  maxillary,  also  a  large  portion  of  their  pal- 
atine processes,  the  approximal  parts  of  the  palatine  processes  of  the 
palatine  and  the  turbinated  bones  had  ])een  destroyed.  The  soft 
palate,  the  uvula,  and  the  tonsils  were  uninjured. 

"  In  looking  into  the  nasal  cavity,  the  walls  of  the  antrum  on  the 
left  side  were  found  deficient,  and  ends  of  the  roots  of  the  incisors 
exposed  and  decayed.  The  tongue  was  visible  through  the  opening 
in  the  palatine  arch.  The  size  and  shape  of  this  orifice  are  repre- 
sented by  the  outer  central  line  in  Fig.  115. 

Pig.  115. — Internal  View  of  Superior  Arcu. 


"Although  desirable,  it  was  deemed  unsafe  to  remove  the  diseasec 
roots,  owing  to  the  yielding  nature  of  the  superior  maxillary  bonesJ 
The  disease  appeared  to  be  arrested,  and  the  parts  in  a  sufficiently 
healthy  condition  to  warrant  the  application  of  the  substitute  ;  anc 
time  has  verified  this,  as,  with  the  exception  of  the  exfoliation  of 


OBTURATORS.  673 

small  scale  from  one  of  the  superior  maxillary  bones,  aVjout  nine 
months  since,  no  change  has  taken  place  up  to  this  date. 

"  The  first  step  in  the  operation  was  to  procure  an  impression  that 
would  enable  me  to  make  a  perfect  model  of  all  the  parts  involved, 
and  their  surroundings,  in  their  relative  positions.  For  this  purpose 
plaster  was  best  adapted,  but  its  use  was  precluded  by  the  acrid  se- 
cretions in  the  nasal  cavity;  wax  and  paraffin  was  considered  the 
best  substitute,  and  used.  Owing  to  the  rigidity  of  the  upper  lip, 
I  was  unable  to  use  the  ordinary  impression  cup  with  success, 
and  was  obliged  to  take  a  rough  impression  of  the  palatine  arch, 
from  which  a  model  was  made,  and  a  metallic  impression  cup 
swaged. 

"  A  sufficient  quantity  of  paraffin  and  wax  was  placed  in  warm 
water,  and,  with  an  assistant  to  keep  it  at  the  proper  temperature,  the 
mode  of  procedure  was  as  follows :  a  proper  quantity  of  the  com- 
pound was  placed  in  the  cup,  introduced  into  the  mouth,  and  pressed 
up  firmly  against  the  arch ;  the  part  forced  into  the  palatine  fissure 
was  at  the  same  time  pressed  with  the  finger,  introduced  through 
the  nasal  cavity,  so  that  it  should  give  an  accurate  impression  of  its 
lateral  boi'ders.  A  groove  was  then  cut  in  this  to  serve  as  a  key, 
and,  after  oiling  it,  a  piece  of  the  compound  was  introduced  through 
the  orifice  of  the  nasal  cavity,  and  passed  down  to  make  the  impres- 
sion of  the  floor  of  the  nasal  cavity.  When  sufficiently  hard  it  was 
carefully  removed,  the  upper  surface  trimmed,  placed  in  cold  water 
to  give  it  its  greatest  firmness,  then  introduced  into  the  cavity,  and 
pressed  into  its  proper  position.  The  metallic  cup  containing  the 
impression  of  the  palatine  arch  was  then  removed.  The  next  stej) 
was  to  take  an  impression  of  the  sides  of  the  cavity,  then  the  top, 
using  a  curved  wooden  spatula  to  press  the  compound  in  proper  posi- 
tion, being  careful  to  mark  or  key  the  parts  that  came  in  contact, 
and  have  their  surfaces  oiled,  to  prevent  adhesion;  and  also  that  the 
pieces  should  be  thinner  in  front  than  in  their  posterior  parts,  so  that 
when  the  four  pieces  forming  the  impression  of  the  base,  sides,  and 
top  were  in  their  proper  position,  they  would  leave  a  tapering  cavity, 
with  its  largest  diameter  at  the  front  orifice.  Into  this  orifice  was 
forced  a  plug  or  cone  of  the  compound,  filling  it  completely ;  in  the 
front  of  this  piece  were  inserted  pieces  of  match  sticks,  to  cause  it  to 
adhere  to  the  next  piece  or  mask.  The  head  was  now  thrown  back 
to  nearly  a  horizontal  position,  wet  tissue  paper  was  placed  over  the 
eyebrows  and  lashes,  the  face  oiled,  and  plaster  mixed  thick  was 
batted  on  with  a  brush.   When  set,  this  was  removed,  drawing  with 

43 


674 


ORAL  DISEASES  AND  SURGERY. 


it  the  central  plug  or  cone ;  the  dififerent  parts  were  then  carefully 
removed,  and  thrown  into  cold  water  to  give  them  a  consistency  to 
bear  handling  without  danger  of  injury.  On  this  central  cone  all 
the  parts  were  placed  in  their  proper  position,  and  the  impression  of 
the  palatine  arch  was  adjusted  in  its  proper  place.  From  this  a 
plaster  model  was  made,  giving  the  upper  part  of  the  face,  cavities, 
palatine  arch,  all  correctly  in  their  relative  positions. 

"  Of  the  different  substances — leather,  wood,  wax,  metal  enameled, 
and  porcelain — used  for  making  artificial  noses,  I  gave  the  preference 
to  hard  rubber  in  this  case,  on  account  of  its  rigidity,  strength,  light- 
ness, and  less  liability  to  injury  by  accident. 

"  To  prevent  derangement,  it  was  necessary  to  make  the  appliance 
as  simple  as  possible ;  it  consisted  of  two  pieces  :  the  external  nose, 
septum,  and  floor  of  the  nasal  cavity  constituted  one,  having  a  pro- 
jection passing  downward  into  the  palatine  fissure,  as  represented  in 
Figures  115  and  116,  A;  and  the  other,  the  obturator  B,  Fig.  117, 
with  a  projection  rising  upward  into  the  palatine  fissure.     These 

Figs.  116  and  117. — Nose,  with  Attachments. 


projections  were  made  hollow,  so  that  when  the  two  parts  were 
placed  together,  as  in  Fig.  Ill,  there  would  be  a  cavity  or  box 
wherein  the  attachments  could  be  placed. 

"Models  were  made  of  the  compound  of  paraffin  and  wax,  which 


OBTURATORS.  575 

were  strengthened  in  the  weaker  parts  by  imbedding  small  strips  of 
metal  in  their  substance  to  give  sufficient  firmness  to  admit  of  the 
necessary  handling  without  injury.  The  model  was  applied  to  the 
patient,  and  the  nose  trimmed  so  as  to  harmonize  with  his  features. 
They  were  then  imbedded  in  plaster  in  the  usual  manner  for  vulcan- 
ite work,  with  the  exception  that  a  stout  curved  wire  passed  through 
the  artificial  nasal  cavities,  extending  beyond  their  borders,  to  give 
strength  to  the  rods  of  plaster  forming  these  cavities  in  the  matrix, 
and  thus  to  prevent  their  fracture  in  packing. 

"  This  appliance  was  vulcanized  four  hours,  consuming  one  hour 
in  attaining  280°  F.,  at  which  point  it  was  held  one  hour,  and  occu- 
pying the  third  hour  in  elevating  the  temperature  to  320°,  where  it 
was  retained  one  hour.  The  work  was  rather  overdone,  but  not  so 
much  so  as  to  injure  it. 

"  The  two  pieces  were  retained  in  position  by  a  staple  and  slide 
bolt.  In  the  recess  of  the  part  of  the  floor  of  the  nasal  cavity  pro- 
jecting into  the  palatine  fissure  (A,  Fig.  115)  was  inserted  a  gold 
staple.  In  the  recess  of  the  projection  of  the  obturator  passing  into 
the  palatine  fissure  (B,  Fig.  117)  were  the  gold  catch  and  shield  of 
the  slide-bolt.  The  object  of  this  shield  was  to  prevent  any  foreign 
substance  entering  the  slot  and  obstructing  the  movements  of  the 
bolt,  also  to  give  a  base  of  support  to  the  catch.  The  rectangular 
upright  of  the  catch  was  soldered  to  the  shield,  passed  through  it 
and  a  longitudinal  slot  in  B,  and  securely  fastened  to  a  rubber  slide 
inlaid  longitudinally,  and  moving  freely  in  the  lingual  surfiice  of  the 
obturator.  On  the  anterior  end  of  this  slide  was  a  small  rounded 
projection,  which  enabled  the  patient,  when  the  two  parts  of  the 
appliance  were  placed  in  their  proper  position,  with  the  point  of  a 
finger  introduced  into  the  mouth,  to  force  the  slide  backward,  thereby 
to  pass  the  catch  into  the  staple  and  firmly  secure  the  apparatus,  or 
by  drawing  the  slide  forward,  detach  the  parts  when  desirable  to 
remove  them. 

"  The  external  nose  was  painted  with  oil  color,  to  give  it  as  nearly 
a  flesh  tint  as  possible,  although  this  is  not  attainable  upon  an  opaque 
ground.  Flesh  being  translucent,  a  true  imitation  can  only  be  made 
upon  a  translucent  ground. 

"  The  apparatus  was  introduced  on  June  30th,  1863,  giving  to 
the  patient  great  satisfaction  and  comfort.  His  appearance  was 
much  improved,  as  may  be  judged  by  comparing  Figs.  lU  and  118, 
which  were  engraved  from  photographs.  He  breathes  freely  through 
the  nose,  and  speaks  with  ease ;  the  only  imperfection  in  his  speech 


676 


ORAL  DISEASES  AND  SURGEBY. 


is  a  nasal  twang,  and  this  is  less  now  than  when  the  instrument 
was  first  applied.     The  obturator  at  first  extended  too  far  back,  and 

¥iQ.  118. — TuE  Face,  with  Nose. 


caused   some   irritation   of   the   velum ;    this    defect   was    readily 
remedied. 

"The  operation  proved  entirely  satisfactory,  with  two  exceptions: 
first,  the  color  of  the  nose  was  not  as  natural  as  desirable,  for  the 
reason  already  stated ;  second,  in  deglutition  and  speech,  when  the 
tongue  pressed  forcibly  against  the  posterior  part  of  the  obturator, 
an  unpleasant  vibratory  movement  of  the  apex  of  the  nose  was 
noticeable.  This  could  have  been  remedied  by  an  elastic  attach- 
ment coupling  the  two  parts  of  the  apparatus,  but  this  mode  was 
objectionable  by  reason  of  its  producing  constant  pressure  upon  the 
delicate  parts,  and  thereby  endangering  absorption.  A  safer  plan 
was  adopted  by  inserting  a  small  steel  pin  in  the  nose  as  near  as 
possible  to  its  apex,  to  which  was  attached  the  bridge  of  a  pair  of 
spectacle  frames,  these  being  retained  in  position  by  an  elastic  cord 
attached  to  the  bows  and  passing  around  the  head.  This  arrange- 
ment answered  the  double  purpose  of  counteracting  the  vibratory 


I 


OBTUBATORS. 


677 


movement,  and  the  bridge  of  the  frames  concealing  the  upper  part 
of  the  joint  where  the  nose  came  in  contact  with  the  face,  which 
was  most  conspicuous. 

"  This  apparatus  is  worn  with  ease  and  comfort  by  the  patient." 

The  obturator,  although  employed  by  the  ancient  Greeks,  and 
by  every  succeeding  generation  of  civilized  men,  seems  to  have 
attained  to  its  wonderful  completeness  only  in  our  own  age.  Be- 
fore the  time  of  Ambrose  Pare,  the  appliances  were  all  of  a  tem- 
porary nature,  if  we  except  mention  of  one  suggested  by  Petro- 
nius,  in  the  sixteenth  century,  although  whether  this  surgeon  ever 
really  made  such  a  plate  as  he  described,  we  are  not  informed.  To 
Pare,  however,  we  are  indebted  for  a  written  description  of  the 
metal  obturator,  crude,  without  doubt,  but  embracing  the  principles 
of  the  present  instruments.  "  Made,"  says  this  surgeon,  "  like  unto 
a  dish  in  figure,  and  on  the  upper  surface,  which  shall  be  toward 
the  hair,  a  little  sponge  must  be  fastened,  which,  when  it  is  moist- 
ened with  the  moisture  distilling  from  the  brain,  will  become  swollen 
and  puffed,  so  that  it  will  fill  the  concavity  of  the  palate,  that  the 
artificial  palate  cannot  fall  down,  but  stand  fast  and  firm  as  if  it 
stood  of  itself" 

Garangeot,  in  ltl5,  makes  an  advance  on  the  idea  of  Pare — 
although,  it  must  be  admitted,  a  very  slight  one.  He  describes  his 
instrument  as  having  a  stem  in  the  form  of  a  screw,  upon  which 
ran  a  nut.  To  make  use  of  it,  he  cut  a  piece  of  sponge  in  the  form 
of  a  hemisphere,  with  a  flat  surface ;  through  this  sponge  the  stem 
was  passed,  the  nut  holding  it  in  place.  When  about  to  introduce 
it,  he  wet  the  sponge,  then  squeezed  it  dry,  and  forced  it  through 
the  aperture  or  break. 

After  the  period  of  Garangeot,  no  special  advances  seem  to  have 
been  made  until  1828,  when  obturators  were  constructed  by  a  Mr. 
Snell,  prepared  on  casts,  which  were  correct  representations  or  im- 
pressions of  the  special  cases.  In  a  monograph  published  by  this 
writer,  he  says:  "My  method  of  constructing  an  obturator  is  with 
a  gold  plate,  accurately  fitted  to  the  roof  of  the  mouth,  extending 
backward  to  the  os  palati,  or  extremity  of  the  hard  palate  ;  a  part  of 
the  plate,  about  an  inch  in  length,  being  carried  through  the  fissure. 
To  that  part  of  the  plate  which  answers  to  the  nasal  fossae  are  sol- 
dered two  plates,  meeting  in  the  center  and  carried  upward  through 
the  fissure  to  the  top  of  the  remaining  portion  of  the  bones,  to  which 
it  should  be  exactly  adapted,  and  made  to  the  natural  shape  of  the 


678  ORAL  DISEASES  AND  SURGERY. 

nasal  palatine  floor ;  thus  the  fluids  of  the  mouth  will  be  carried 
backward  into  the  fauces.  A  piece  of  prepared  elastic  gum  is  next 
attached  to  the  posterior  part  of  the  plate  where  the  natural  soft 
palate  commences,  extending  downward  on  each  side  as  low  as  the 
remaining  part  of  the  uvula,  and  grooved  at  its  lateral  edges  to  re- 
ceive the  fissured  portions  of  the  velum;  a  movable  velum  is  placed 
in  the  posterior  center  of  the  elastic  gum.  That  these  may  partake 
of  the  natural  movements  of  the  parts  during  deglutition,  a  sponge 
is  aSixed  behind  them,  one  end  of  which  is  attached  to  the  posterior 
and  anterior  surfaces  of  the  principal  plate,  and  the  other  end  rests 
gently  against  the  posterior  face  of  the  india-rubber:  this  keeps 
it  always  in  close  apposition  with  the  edges  of  the  fissure  during 
deglutition. 

"It  is  requisite  to  mention,"  he  says,  "that  the  elastic  gum 
should  be  placed  in  a  gold  frame,  and  not  merely  fastened  to  the 
posterior  part  of  the  plate,  as  it  would  shrink  up  by  remaining  in 
the  mouth.  This  frame  should  pass  round  its  edges  only,  leaving 
the  center  upon,  etc." 

In  1845,  Mr.  Stearn,  a  surgeon  of  London,  conceived  the  idea  of 
an  obturator,  the  principle  of  which  has  been  brought  to  such  per- 
fection by  Dr.  Norman  W.  Kingsley,  of  the  Dental  College  of  New 
York.*  This  appliance,  as  made  by  Mr.  Stearn,  consisted  of  a  gold 
plate  fitted  to  the  hard  palate,  having  attached  to  it,  by  means  of 
two  spiral  springs,  an  artificial  velum  of  elastic  rubber,  consisting  of 
a  body,  wings,  and  grooved  edges,  to  receive  the  margins  of  the 
cleft.  The  conception  of  this  obturator  reflects  the  greatest  praise 
upon  Mr.  Stearn,  an  honor  which  Dr.  Kingsley  may  feel  it  no 
detraction  to  share  with  him. 

The  perfected  instrument  of  Dr.  Kingsley,  though  greatly  differing 
from  that  of  Mr.  Stearn,  consists  likewise  of  a  body  with  movable 
wings.  These  wings,  made  of  soft  rubber,  fill  up  the  break  in  the  soft 
palate,  being  moved  by  the  lateral  remnants  of  the  defective  parts. 

With  respect  to  this  obturator,  so  much  experience  seems  to  have 
accumulated  that  its  great  usefulness  can  no  longer  be  doubted. 

Concerning  the  mode  of  manufacture,  taking  the  impressions,  and 
a])plying  the  piece,  full  details  can  be  found  in  Harris's  Principles 
and  Practice  of  Dental  Surgery,  edition  of  1863. 


*  Dupuytren,  the  eminent  French  surgeon,  is  not,  as  it  seems  to  me,  with- 
out same  claim  to  a  share  in  this  invention ;  his  idea,  however,  was  very 
crude. 


CHAPTER    XLII. 

RESECTIONS   OF   THE   MAXILLARY   BONES. 

The  history  of  experimental  surgery  upon  the  bones  of  the  face 
furnishes  one  of  the  most  interesting  of  the  chapters  in  surgery. 
The  formation  upon  and  within  these  bones  of  such  diseases  as 
seemed  to  make  desirable  their  removal,  necessarily  directed,  from 
a  comparatively  early  period,  the  attention  of  surgeons  to  the  feasi- 
bility, propriety,  and  promises  of  such  operations. 

It  is  not  at  all  unreasonable  to  infer  that  surgery  gained  its  first 
lesson  in  this  direction  by  observing,  through  the  results  of  acci- 
dents, how  extensive  could  be  an  injury  done  to  these  parts  without 
fatal,  or,  indeed,  even  threatening  consequences.  Hence,  as  early 
as  1693,  Acoluthus,  a  surgeon  of  Breslau,  attempted  the  removal  of 
a  portion  of  the  upper  jaw  for  a  tumor,  in  which  operation  he  suc- 
ceeded very  satisfactorily.  Jourdan,  according  to  his  translator,  re- 
moved, at  various  times  during  his  century,  portions  of  the  jaw. 
To  Dr.  Jameson,  an  American  surgeon,  however,  most  are  agreed, 
belongs  the  credit  of  having  made  the  first  complete  resection  or 
removal  of  the  upper  jaw, — this  having  been  done  in  1820.  Prof 
Gross  gives  the  credit  to  Lizars,  of  Edinburgh,  believing  him  en- 
titled to  the  merit  of  having  first  suggested  the  possibility  and 
advantage  of  the  operation.  In  1824,  four  years  later.  Dr.  David 
Rodgers,  of  New  York,  resected  both  superior  maxillae.  Afterward 
this  was  attempted  by  Lizars,  and  in  the  same  year  by  Gensoul,  of 
France.  After  this  the  operations  may  be  esteemed  as  having 
become  commonly  recognized,  surgeons  of  ability  performing  the 
various  sections  throughout  England  and  France,  and  especially  in 

the  United  States. 

While  the  operation  of  resection  has  been  frequently  performed, 
it  cannot  but  surprise  the  surgeon  of  to-day  to  notice  how  slowly 
its  lessons  were  learned.  At  present  it  is  practiced  with  little 
preliminary  caution,  being  esteemed  an  operation  that  may  be  per- 
formed with  really  little  danger  to  the  patient,  and  even  without 
much  damage  to  the  appearance.     Formerly,  and,  indeed,  not  very 

(  679) 


680  ORAL  DISEASES  AND   SURGERY. 

far  back,  it  was  considered  only  safe  to  ligate,  as  a  preliminary  step, 
the  primitive  carotid  artery ;  and  when,  as  experience  advanced, 
this  was  seen  not  to  be  a  necessity,  the  actual  cauterants  were 
always  held  in  readiness,  a  practice  which,  much  to  the  detriment 
of  a  happy  cure,  obtains  in  some  sections  even  to  the  present  day. 

Resections  of  the  maxillary  bones  are  practiced  for  various  dis- 
eases, the  principal  of  which  are  the  malignant  tumors.  That  such 
resections  are  so  often  reported  as  unfavorable,  has  not  been  from 
shock,  or  any  local  injury  done,  but  from  the  fact  that  the  disease 
for  which  the  operation  was  performed  was  in  itself  fatal. 

"  Excision  of  the  upper  jaw,"  says  Mr.  Syme,  "  when  performed 
for  the  removal  of  tumors  which  are  confined  to  that  bone,  is  a  most 
satisfactory  and  successful  operation ;  but  if  the  operation  be  at- 
tempted for  the  removal  of  a  disease  which  has  originated  in  the 
base  of  the  skull,  and  grown  downward,  it  not  only,  as  is  well 
known,  fails  in  its  object,  but  speedily  ends  in  a  fatal  result.  In 
diagnosing  between  a  tumor  of  the  upper  jaw  which  admits  of  re- 
moval and  one  that  does  not,  Mr.  Syme  directs  special  attention  to 
the  appearance  of  the  face.  If  the  eyeball  be  displaced,  and  the 
position  of  the  bones  of  the  nose  be  altered,  the  case  is  one  which 
does  not  admit  of  operative  measures  ;  but  if  these  signs  are  absent, 
and  if  the  history  of  the  case  shows  that  the  disease  began  in  the 
jaw  itself,  then  the  disease  will  most  likely  admit  of  complete  cure 
by  the  excision  of  the  affected  bone.  The  soft  nature  of  some  of  these 
tumors  is  no  hinderance  to  the  performance  of  the  operation,  for  Mr. 
Syme  has  excised  the  upper  jaw  with  a  good  result  in  many  cases, 
where  the  consistence  of  the  tumor  was  quite  as  soft  as  that  of  a 
malignant  growth." 

In  looking,  after  an  interval  of  months,  and,  in  a  few  cases,  of 
years,  at  individuals  upon  whose  jaws  I  have  personally  performed 
resections,  I  have  been  astonished  at  the  correction  on  the  part  of 
nature  of  deformity.  The  little  German  boy,  alluded  to  in  the 
chapter  on  Necrosis  as  having  lost  the  left  half  of  the  inferior  max- 
illa, without  at  the  time  any  reproduction,  looks  to-day  as  though 
no  such  loss  had  ever  occurred ;  his  face  is  exactly  as  it  was  before 
the  operation,  and,  as  far  as  I  can  see,  the  ability  to  masticate,  al- 
lowing for  the  loss  of  the  teeth  on  that  side,  is  about  as  good  as 
ever.  This,  however,  is  an  uncommon  case,  the  result  without 
doubt  of  the  youth  of  the  patient. 

Oilier,  by  his  experiments  upon  the  osteogenetic  properties  of  the 
periosteum,  has  done  good  service  to  oral  surgery.     It  is  now  a 


RESECTIONS  OF  THE  MAXILLABY  BONES 


681 


common  practice  in  all  resections  to  spare  and  save  all  the  tissue 
possible.  I  have,  in  the  chapter  on  Necrosis,  spoken  of  my  own 
success  in  this  direction,  having  replaced  entirely,  with  the  exception 
of  the  alveolar  process  and  teeth,  the  whole  of  the  body  of  the 
lower  jaw  through  the  process  of  enucleation. 

It  is  not  to  be  forgotten,  however,  that  the  seeds  of  a  disease,  so 
to  speak,  may  be  left  in  a  part  by  an  attempted  preservation  of  peri- 
osteal tissue.  This  fact  is  always,  in  all  classes  of  resection,  to  be 
borne  prominently  in  mind  :  periosteal  tissue  is  not  to  be  saved 
unless  healthy. 

To  make  a  complete  resection  of  either  maxilla  implies,  ordinarily, 
a  preliminary  uncovering  of  the  affected  bone.  The  incisions  to 
such  ends  are  necessarily  various,  being  influenced  by  the  condi- 
tion of  the  parts  beneath.  They  are  not,  however,  always  necessary. 
Prof.  Horner,  as  exhibited  in  Plate  XIII.,  has  removed  the  upper 
jaw  of  the  left  side  without  preliminary  incision;  and  in  two  favor- 
able cases  I  have  myself  succeeded,  without  the  slightest  difficulty, 
in  doing  the  same  thing. 

In  the  case  of  tumors  of  magnitude  and  importance,  these  subin- 
tegumental  operations,  in  my  opinion,  are  not  to  be  commended. 
A  wound,  or  incision,  made  to  expose  such  tumors,  may  be  united 
by  the  first  intention,  leaving  little  or  no  scar,  while  certainly  the 
exposure  obtained  through  such  incisions  compensates  by  the  liberty 
and  rapidity  of  movement  allowed  in  the  subsequent  steps  of  an 
operation. 

Subfig.  1  exhibits  the  mouth  of  the  patient  of  the  late  Dr.  Horner, 
immediately  after  the  removal  of  the  superior  maxillary  bone  with- 
out external  incision ;  Fig.  2  is  a  side  view  of  the  bone  removed ; 
and  Fig.  3  is  the  likeness  of  the  patient  taken  three  years  after  the 
operation.  The  operation,  as  practiced  by  Dr.  Horner,  is  thus  de- 
scribed by  his  son-in-law,  Prof.  Smith:  "Having  determined  to 
avoid  cutting  through  the  cheek,  as  commonly  practiced,  the  patient 
was  seated  in  a  chair,  with  his  head  well  supported,  and  partially 
etherized.  The  assistant,  supporting  the  patient's  head,  then  raised 
the  angle  of  the  mouth  on  the  left  side,*  and  held  it  widely  open,  while 
the  upper  lip  and  cheek  were  dissected  from  the  superior  maxilla  as 
far  back  as  possible,  in  a  line  parallel  with  the  superior  margin  of  the 
buccinator  muscle.  The  two  incisor  teeth  on  the  left  side  being  then 
drawn,  the  corresponding  alveoli  were  cut  through  in  the  middle 

*  The  figure,  by  an  error,  is  made  to  show  the  operation  on  the  right  side. 


682  ORAL  DISEASES  AND   SURGERY. 

line  by  a  narrow  saw,  which  worked  its  way  from  the  mouth  into 
the  left  nostril ;  then  a  pair  of  strong  hawk-bill  scissors,  such  as  are 
used  by  gardeners  for  lopping  off  twigs,  took  out  the  two  vacated 
alveoli  at  a  clip. 

"  A  thin,  flat,  well-tempered  knife,  with  a  strong,  round  handle, 
was  now  struck  through  the  roof  of  the  mouth  into  the  nose,  at  the 
junction  of  the  palatine  processes  of  the  palate  and  superior  maxil- 
lary bones  (posterior  middle  palate  suture),  so  as  to  cut  forward  and 
separate  the  maxillary  bones  from  each  other  in  the  middle,  when 
the  narrow  saw  was  again  used  to  cut  through  the  root  of  the  nasal 
process  of  the  maxillary  bone,  and  strong  scissors,  curved  on  the 
flat,  made  to  cut  through  the  orbitar  plate  at  its  margin,  the  inci- 
sion being  carried  back  to  the  pterygoid  process  of  the  sphenoid, 
around  and  below  the  malar  bone. 

"  The  base  of  the  soft  palate  being  then  detached  by  a  short,  trian- 
gular knife,  curved  on  the  flat,  so  as  to  leave  the  soft  palate  attached 
to  the  palate-bone,  a  few  touches  of  the  knife  freed  the  remaining 
attachments. 

"  The  pterygoid  process,  malar  bone,  and  the  orbitar  plate  of  the 
upper  maxillary  were  not  disturbed.  The  tumor, — which  was  scir- 
rhous,— besides  its  bony  connection,  was  also  attached  to  the  poste- 
rior part  of  the  cheek,  and  to  the  external  pterygoid  muscle.  The 
gouge  and  scissors,  however,  sufficed  to  remove  every  part  that 
could  be  detached. 

"  The  bleeding  was  profuse,  especially  from  what  was  believed  to 
be  the  posterior  palatine  artery,  but  the  vessel  was  readily  secured 
by  means  of  a  ligature  and  Physick's  needle,  and  a  few  other  liga- 
tures, with  charpie,  arrested  the  remainder  of  the  hemorrhage." 

The  ordinary  operation  for  the  removal  of  the  superior  maxillary 
bone  I  may  now  proceed  to  describe  in  detail. 

If  the  disease  for  which  such  an  operation  is  to  be  performed  is  a 
tumor  of  moderate  dimensions,  say  scirrhus,  as  in  Prof  Horner's  case, 

which  seldom  attain  to  large  size, — the  uncovering  of  the  part  is 

to  be  effected  by  dividing  the  superior  lip  in  the  middle  line,  carrying 
the  incision  upward  along  the  base  of  the  ala  of  the  diseased  side  to 
the  inner  canthus ;  the  flap  thus  secured,  which  is  triangular,  is  dis- 
sected off  as  far  as  possible.  Now  remove  the  central  teeth,  and, 
with  a  scalpel,  make  an  incision  along  the  middle  line  of  the  hard 
palate  as  far  back  as  the  palato-maxillary  articulation  ;  at  right  an- 
gles with  this  incision  make  a  second,  extending  to  the  tuberosity  of 
the  maxilla,  the  cut  to  be  as  nearly  as  possible  on  the  line  of  the 


RESECTIONS   OF  THE  MAXILLARY  BONES.       683 

articulation.  Examining  at  this  stage  a  skull,— which  it  is  never 
amiss  to  have  by,— take  up  a  Hey's  saw,  and  cut  across  the  nasal 
process,  leaving,  if  possible,  the  orbital  plate.  Next,  with  the  same 
saw,  cut  across  the  maxillo-malar  articulation;  this  completes  the 
two  upper  sections.  The  third,  the  intermaxillary,  is  quickly  effected 
by  introducing  within  the  nostril  one  blade  of  the  large  cutting  for- 
ceps, the  other  being  placed  on  the  line  of  the  articulation  within  the 
mouth,  as  far  back  as  the  point  of  union  with  the  palate-bone ;  the 
incision  is  now  made,  and  the  separation,  so  far  as  cutting  is  con- 
cerned, is  completed.  Take  now  a  pair  of  strong  forceps,  and,  seiz- 
ing the  bone,  twist  it  from  its  bed. 

The  hemorrhage,  the  matter  next  demanding  attention,  varies  very 
much  with  circumstances.  It  may  be  that  twenty  arteries  will  jet 
their  blood  into  the  face  of  the  operator,  or,  on  the  contrary,  only 
two  or  three  may  require  artificial  means  for  their  control.  One 
need  neither  be  hasty  nor  timid  about  this  bleeding.  Water,  fully 
saturated  with  alum,  simply  squeezed  into  the  cavity  from  a  sponge, 
will  oftentimes  control  it.  If  this  should  not  answer  the  purpose,  a 
syringe  may  be  used,  throwing  the  water  against  the  vessels  from 
some  little  distance.  The  casting  of  a  ligature  around  a  vessel  is, 
however,  a  matter  as  easy  as  it  is  simple.  Wash  away  the  blood 
until  the  orifice  of  the  bleeding  artery  can  be  seen,  catch  it  with  the 
tenaculum,  or  forceps,  draw  it  thus  a  little  from  its  sheath,  and  tie  it. 
Repeat  this  with  each  vessel  until  all  are  secured. 

That  proper  form  and  support  may  be  given  to  the  integuments, 
the  next  step  in  the  operation  is  the  stuffing  of  the  wound.  To  do 
this,  take  a  number  of  pieces  of  old  linen,  or  patent  lint,  fold  them 
into  small  squares,  saturate  these  freely  with  alum- water,  and,  one 
by  one,  pack  them  into  the  cavity  until  the  contour  of  the  part  shall 
correspond  with  that  of  the  other  side.  The  surgeon  is  to  remem- 
ber how  many  of  these  squares  he  has  used,  that  thus  he  may  have 
the  assurance  at  a  future  period  that  all  have  been  removed. 

Rotundity  and  form  secured,  the  flap  is  next  laid  carefully  into 
place,  and  closely,  yet  not  tightly,  approximated  by  a  sufBcicnt  num- 
ber of  stitches  of  the  interrupted  suture.  It  is  generally  the  best 
plan  to  put  a  pin  or  stitch  first  in  the  lip,  thus  insuring  correct  ap- 
proximation at  this  most  important  point. 

•'As  a  dressing,  simple  cold  water  may  be  used,  keeping  the  parts 
constantly  cool  by  its  continuous  renewal ;  or,  if  water  alone  is  found 
insufficient  to  control  vascular  excitement,  it  may  be  medicated  with 
lead  in  the  proportion  of  3ij  to  ^xvi ;  cold  water,  however,  will  gen- 
erally be  found  all-sufficient. 


684  ORAL  DISEASES  AND  SURGERY. 

Concerning  the  pads  or  squares  inside,  I  am  confident  it  will  be 
found  the  very  best  practice  never  to  allow  them  to  dry  from  the 
time  of  their  first  introduction.  This  is  easily  prevented  by  repeated 
syringing  with  pure  water,  or  water  medicated  with  stimulants, 
astringents,  sedatives,  or  antiphlogistics,  as  indicated. 

The  stitches  used  in  approximating  the  external  wound  are  to 
be  removed  as  soon  as  possible, — three  or  four  days  will  generally 
allow  of  such  removal.  It  is  well  to  remove  them  gradually,  taking 
away  intermediate  ones. 

The  removal  of  the  squares  is  to  be  effected  leisurely — indeed,  the 
principle  is  to  consider  them  as  a  tent,  to  be  thrown  out  as  the 
wound  granulates  and  fills  up  below  them ;  pick  out  the  top  or  mid- 
dle ones,  as  the  irritation  produced  by  their  overretention  compels 
you.  Or,  if  it  seems  necessary,  after  the  first  three  days  have  ' 
passed,  they  may  all  be  removed  and  renewed,  in  lessening  numbers, 
daily. 

This  completes  the  surgical  proceedings  of  such  a  resection.  . 

Many  cases,  however,  occur  where  the  external  incision  here  I 
suggested  might  not  be  the  best  one,  and,  indeed,  where  it  might 
not  be  sufficient  to  uncover  the  disease.  Certain  surgeons  prefer  to 
expose  the  bone  by  an  incision,  commencing  at  the  angle  of  the  | 
mouth,  and  passing  obliquely  upward  over  the  Stenonian  duct  to 
the  center  of  the  malar  bone,  throwing  thus  the  flap  upward  and 
inward  from  below.  Another  favorite  mode  is  to  use  both  these 
incisions  upon  the  same  subject,  a  necessary  proceeding,  in  many 
cases,  where  the  tumor  is  large. 

"  Mr.  Fergusson,  who  is  particularly  successful  in  oral  surgery, 
in  remarks  after  an  operation  for  the  removal  of  disease  affecting 
the  alveolus  and  antrum,  made  some  important  and  interesting  ob- 
servations, having  reference  generally  to  the  exposure  of  such  parts 
prior  to  the  removal  of  the  actual  disease.  He  said  that  formerly, 
and  even  now,  some  surgeons  were  in  the  habit  of  freely  dividing 
the  integument  of  the  cheek,  lip,  etc.,  trying  to  get  at  the  disease 
from  various  points.  Mr.  Fergusson  said  that  one  method  he  pur- 
sued with  advantage  (as  in  a  case  of  removal  of  malignant  disease 
of  the  upper  jaw),  was  to  divide  the  upper  lip  in  the  median  line, 
and  then  by  carrying  the  incision  on  one  or  both  sides,  as  the  cir- 
cumstances of  the  ease  required  it,  into  the  nose,  to  dissect  back**he 
upper  lip,  ala  nasi,  and  cheek,  and  thus  expose  the  parts  freely, 
avoid  the  deformity  of  scar  on  the  cheek,  or,  to  use  his  words,  '  to 
leave  as  few  mai-ks  of  the  surgeon's  doings  on  the  face  as  possible.' 


RESECTIONS   OF  THE  MAXILLARY  BONES 


G85 


lu  a  case  then  before  him— a  young  woman— he  was  able  to  remove 
the  disease  without  interfering  with  the  lip.  It  affected  the  alveolar 
ridge  of  the  right  side,  extending  from  the  second  incisor  to  the 
second  molar,  and  was  continued  into  the  antrum ;  but  whether  it 
first  arose  in  the  antrum  or  the  alveolus,  he  did  not  know.  Mr.  Fer 
gusson  attributed  the  success  attending  this  method  of  removal,  in 
a  great  measure,  to  the  instrument  he  used,  viz.,  a  pair  of  clipping 
forceps.  He  first  clipped  away  the  alveolar  ridge,  and  then  attacked 
the  portion  of  disease  situated  in  the  neighborhood ;  by  this  means 
freely  laid  open  the  antrum  and  nostril.  He  alluded  to  a  case  in 
which  Mr.  Bowman  successfully  removed  a  large  tumor  from  the 
antrum  extending  into  the  mouth,  without  dividing  the  lips." 

Such  a  mode  of  uncovering  a  tumor  of  limited  size  is  admirable : 
the  section  will  be  found  to  make  a  large  exposure,  and  the  scar  left 
will  scarcely  be  remarked. 

Operation  for  Resection  of  both  Superior  Maxilla. — It  has 
never  fallen  to  my  lot  to  resect,  or  to  see  resected,  both  maxillary 
bones.  Several  such  operations  are,  however,  on  record ;  and  from 
them  I  select  that  of  Heyfelder,  as  being  the  one  I  myself  should 
perform  should  such  a  necessity  arise. 

The  patient  is  to  be  seated  in  a  chair,  with  his  head  supported 
by  an  assistant,  or,  better,  he  may  lie  down.  An  incision  is  made 
on  each  side  of  the  face,  from  the  external  angle  of  the  eye  to  the 
labial  commissure  ;  the  included  parts  are  now  reflected  upward 
toward  the  forehead  until  the  infraorbital  ridges  are  exposed.  This 
uncovers  the  whole  of  both  bones.  The  chain  saw  is  now  passed 
through  the  spheno-maxillary  fissures,  the  malar  bones  are  divided, 
the  maxillse  separated  from  the  ossa  nasi,  and  the  vomer  and  thinner 
bones  are  cut  wuth  strong  scissors.  These  steps  complete  the 
separation,  when  the  bones  are  to  be  pried  from  the  cavities  with 
elevators  or  twisted  away  with  the  lion  forceps  of  Liston.  The  re- 
sult of  an  operation  thus  performed  by  Heyfelder  is  thus  described : 
"Very  little  blood  was  lost,  torsion  and  compression  sufficing  to 
arrest  the  hemorrhage.  Two  hours  afterward,  the  edges  of  the 
wounds,  from  the  angles  of  the  eyes  to  the  corners  of  the  mouth, 
being  united  by  twenty-six  stitches  of  the  interrupted  suture,  cold 
lotions  were  applied :  there  was  no  reaction  or  swelling,  and  the 
patient  could  swallow  water  and  broth.  Four  days  subsequently, 
the  wounds  had  nearly  healed  by  the  first  intention,  and  in  six  weeks 
the  patient  was  exhibited  to  the  Medical  Society  of  Erlachen.  At 
this  time  there  was  no  deformity  of  the  features :  a  fissure,  thirteen 


686  ORAL  DISEASES  AND   SURGERY. 

lines  long  and  three  lines  wide,  was  seen  along  the  median  line  of  his 
mouth;  the  soft  palate  and  uvula  were  in  their  natural  place;  deglu- 
tition was  free  ;  the  nose  had  resumed  its  original  form  and  direction; 
and  the  face,  which,  before  the  operation,  was  like  that  of  a  monkey, 
again  possessed  a  human  expression;  a  firm  and  solid  tissue  re- 
placed the  extirpated  parts." 

Professor  Gross,  while  commending  that  any  operation  for  the 
removal  of  the  upper  jaw  should  be  preceded  by  a  careful  inquiry 
into  the  history  of  the  case,  is  not,  from  his  experience,  inclined  to 
admit  that  encephalomatous  tumors  are  to  be  esteemed  as  always 
hopeless  to  operative  interference.  "  If  the  tumor,"  says  this  gen- 
tleman, "  be  large  in  size,  rapid  in  its  development,  dipping  into  the 
surrounding  structures,  and  attended  with  contamination  of  the 
neighboring  absorbent  glands,  failure  of  the  general  health,  and  a 
sallow,  cadaverous  countenance,  all  manual  interference  is  out  of  the 
question.  On  the  other  hand,  however,  there  is  no  reason,  in  my 
opinion,  for  refraining  from  the  use  of  the  knife,  even  in  this  form  of 
disease,  provided  the  morbid  growth  is  comparatively  small  and 
tardy  in  its  progress,  and  the  surrounding  parts  and  constitution 
are  perfectly  sound."  Professor  Gross  thinks  the  propriety  of  such 
a  course  is  sanctioned  by  the  experience  of  the  best  surgeons. 

Concerning  hemorrhage,  this  same  gentleman  gives  it  as  his  expe- 
rience that  there  are  no  organs  in  the  body  of  the  same  extent  in 
their  natural  and  diseased  conditions,  the  removal  of  which  is  at- 
tended with  less  trouble  in  this  direction.  "  I  rarely,  if  ever,"  he 
says,  "  stop  to  tie  a  vessel  during  any  operation,  however  extensive 
or  complicated."  My  experience  has  taught  me  that  there  is,  in 
general,  no  necessity  for  such  a  course,  which  is  always  attended 
with  vexation  and  delay.  The  deep-seated  arteries  involved  in 
tumors  of  the  upper  jaw  seldom  bleed  much,  if  care  be  taken  to 
keep  beyond  the  limits  of  the  diseased  structures.  If  this  precau- 
tion be  neglected,  the  hemorrhage  may  be  copious  and  even  ex- 
hausting. 

Kesections  of  the  Inferior  Maxilla — in  whole  and  in  part. 
— Partial  resections  of  the  lower  jaw  have  become  so  common  as  to 
elicit  little  attention.  I  have  myself  certainly  made  such  sections  in 
as  many  as  fifty  cases.  The  causes  necessitating  such  operations  are 
considered  in  other  parts  of  this  work.   (See  Chapters  on  Tumors.) 

Subfigures  6,  Y,  and  8,  Plate  XIII.,  exhibit  various  steps  in  such 
resection,  and  are  photographically  true,  allowing  for  the  absence  of 
the  blood. 


RESECTIONS  OF  THE  MAXILLARY  BONES.        687 

Complete  section  of  the  lower  jaw  is  one  of  the  most  disfi-urin- 
and  comfort-destroying  operations  that  can  be  practiced  on  thHivin^ 
being,  and  is  never  to  be  performed  without  the  existence  of  a  well- 
recognized  or  proven  necessity.  Any  partial  section  anterior  to  the 
rami  may  generally  be  easily  accomplished  without  external  wound 
the  hps  being  held  out  of  the  way  by  the  mouth-stretcher  used  in 
the  performance  of  dental  operations. 


Fig.  119.— Mouth-Stretcher  applied. 


it^.SCBALD. 


In  cases  where  section  of  the  lip  may  be  thought  desirable,  as 
when  the  practitioner,  from  inexperience,  may  not  be  able  to  accom- 
plish the  section  without  the  exposure,  various  cuts  are  proposed  and 
required.  These  cuts  may  be  fully  understood  by  the  studies  pre- 
sented. Subfigure  8,  Plate  XIII.,  represents  exposure  of  the  mental 
portion  of  the  bone.  The  flaps,  1,  2,  are  made  b}'  a  single  vertical 
incision  through   the  median  line  of  the  lower  lip,  crossed  by  a 


688  ORAL  DISEASES  AND   SURGERY. 

second  at  right  angles  at  the  base  of  the  jaw,  extending  on  either  side, 
laterally,  as  far  as  the  bone  is  required  to  be  removed. 

Subfigure  7  represents  the  exposure  of  the  whole  left  half  of  the 
jaw.  To  accomplish  this,  make  a  first  incision  in  the  median  line 
to  the  under  border  of  the  bone.  From  this  carry  a  second  under 
the  jaw — although  along  it — to  the  temporo-maxillary  articulation. 
Dissect  now  the  flap  upward.  In  the  horizontal  cut  here  made  it 
will  be  perceived  that  the  facial  artery  is  divided ;  this  is  a  large 
vessel,  and  requires  a  ligature.  It  will  be  found,  I  think,  the  better 
practice  to  tie  both  ends  before  proceeding  to  the  operation  upon  the 
bone.  The  coronary  artery  cut  in  the  vertical  incision  will  often 
compel  a  ligature. 

Subfigure  6  exhibits  an  exposure  of  the  whole  body  of  the  bone. 
This  is  accomplished,  as  in  the  drawing,  by  a  simple  horizontal  in- 
cision along  the  base  of  the  jaw,  carried  from  angle  to  angle,  and  the 
flap,  including  the  mouth  entire,  thrown  up  ;  or  it  may  be  secured 
by  joining  the  horizontal  to  a  vertical  incision  made  from  the  angle 
of  the  mouth ;  or,  as  in  Fig.  8,  by  the  median,  vertical,  and  horizon- 
tal incisions.  These  sections  understood,  any  required  modification 
will  suggest  itself 

Subfigures  4,  5,  6,  represent  an  operation  practiced  by  Dr.  J. 
Rhea  Barton :  4  exhibits  the  tumor,  which  will  be  seen  to  be  of 
great  bulk,  being  described  as  having  complete  possession  of  the 
mouth,  forcing  the  tongue  into  the  pharynx,  and  stretching  the  jaws 
widely  apart.  It  also  rose  up  outside  the  superior  maxillary  bone, 
protruding  the  lips,  cheek,  and  neck  on  the  left  side. 

Finding,  by  examination,  that  the  base  of  the  bone  might  be  left 
with  promise,  Dr.  Barton  made  the  resection  as  exhibited  by  the 
lines  in  5.  This  was  accomplished  by  sawing  horizontally  from 
without  inward,  commencing  at  the  middle  line  below  the  canal, 
and  extending  the  section  bilaterally.  The  removal  of  the  bone, 
in  this  particular  operation,  gave  no  hemorrhage  requiring  attention. 
The  flaps  being  replaced  and  stitched,  the  patient  was  well  in  a 
month. 

Complete  section  of  the  jaw,  as  exhibited  in  Fig.  8,  after  the  prac- 
tice of  Dupuytren  and  many  successors,  destroys  forever  the  articu- 
lation of  the  jaws,  and  interferes  not  only  with  mastication,  but  seri- 
ously with  deglutition  and  speech.  Exposing  the  bone  as  directed, 
the  section  is  most  easily  made  with  either  the  Hey,  metacarpal,  or 
chain  saw.  Before,  however,  shaving  the  bone  from  its  inner  attach- 
ments, a  loop  of  waxed  silk,  or  silver  wire,  is  to  be  passed  through 


BESECTIONS   OF  THE  MAXILLARY  BONES. 


G89 


the  tip  of  the  tongue,  that  it  may  thus  bo  prevented  from  being  drawn 
back  into  the  pharynx  by  the  g-enio-hyoid  and  stylo-hyoid  nmseles. 

Subfig-ure  1  exhibits  the  removal  of  one-half  the  maxilla.  Expos- 
ing the  bone  as  directed,  remove  one  or  more  of  the  center  teeth  ; 
next,  from  without  inward,  saw  through  the  bone,  or,  if  preferred, 
use  the  chain  saw,  carrying  it  around  the  bone  by  the  aid  of  a  curved 
needle.  Catching  now  the  bone  in  the  gra.sp  of  the  forceps,  or  using 
the  fingers,  as  preferred,  detach  the  inner  soft  parts,  twisting  the 
bone  outward  and  downward.  Arriving,  in  the  dissection,  at  the 
coronoid  process,  the  temporal  tendon  is  to  be  detached  by  a  chisel- 
shaped  knife,  care  being  taken  not  to  wound  the  maxillary  artery  or 
internal  carotid.  This  process  freed,  the  condyle  can  be  twisted 
from  its  ligaments,  or,  better  still,  twisted  and  cut  away.  This 
operation,  apparently  so  formidable,  I  once  succeeded  in  doing  with- 
out external  incision.  With  the  section  as  represented  in  the  figure, 
it  is  not  at  all  difficult.  A  diseased  bone  is  not,  I  am  convinced, 
nearly  so  difficult  to  disarticulate  as  the  sound  one. 

Prof.  Smith,  in  his  System  of  Surgery,  gives  the  credit  to  Dr. 
Geo.  McClellan  of  having  been  the  first  to  attempt  more  than  a  lim- 
ited section  of  this  bone, — this  surgeon,  in  1823,  removing  all  the 
parts  anterior  to  the  angles.  In  this,  however,  he  was  preceded  l)y 
Deaderick,  of  Tennessee,  who,  in  1812,  made  a  resection  which  ex- 
tended from  the  symphysis  to  the  angle.  Mott,  of  New  York,  is 
also  referred  to  as  having  made  an  operation  similar  to  Deaderick's, 
in  1821.  Dr.  Ackley,  of  Cleveland,  Ohio,  is  reported  as  having,  in 
1850,  removed  the  bone  entire.  In  Europe,  priority  of  the  operation 
performed  first  by  Deaderick  is  awarded  to  Dupuytren.  Mott,  ac- 
cording to  Prof.  Smith,  disarticulated  the  bone, — Deaderick  and  Du- 
puytren did  not.  Prof  Mott  thought  it  necessary  to  ligate  the 
primitive  carotid  artery  a  few  days  before  making  his  resection,  a 
step  long  since  proved  to  be  entirely  uncalled  for,  complicating  and 
increasing  the  dangers  of  the  operation. 

The  operation  of  Dr.  Deaderick,  deservedly  famous  for  its  priority, 
was  done  on  the  person  of  a  lad  fourteen  years  of  age.  The  operation 
was  performed  for  the  removal  of  a  cartilaginous  tumor  on  the  left 
side  of  the  jaw,  filling  up  nearly  the  whole  of  the  mouth,  causing  the 
greatest  difficulty  in  swallowing,  and,  at  times,  even  in  breathing.  To 
accomplish  his  resection,  Dr.  Deaderick  commenced  an  incision  under 
the  zygomatic  process,  and  carried  it  across  the  tumor,  downward 
and  forward,  to  nearly  an  inch  beyond  the  middle  of  the  chin.  From 
the  center  of  this  first  incision,  and  consequently  at  right  angles  with 

44 


090 


ORAL   DISEASES   AXD   SURGERY. 


it,  au  incision  was  extended  a  short  distance  upon  the  neck.  The 
flaps  thus  secured  were  dissected  from  the  diseased  mass,  and  the 
bone  next  sawed  off  at  the  angle  and  sj'mphysis.  The  flaps  were 
now  laid  back  in  the  usual  way,  and  the  boy  made  a  speedy  recovery. 
Nerve  Section. — A  most  interesting  department  of  resective  sur- 
gery— for  thus  it  may  be  termed — is  found  in  the  operations  required 
to  expose  nerves  involved  in  neuralgic  lesions.  It  is  certainly  no 
longer  a  question  that  sections  of  nerve-cords  may  be  made  without 
special  danger  or  risk, — the  greater  question  being  always  the  estab- 


FiG.  120. 


,jj,    "-— 1^|_-,._ 


lishment  of  a  coi'rect  diagnosis.  In  the  chapter  on  Neuralgia  I  took 
occasion  to  remark  that  such  operations  were  far  from  being  satis- 
factory;  but  that  remark  is  here  to  be  modified  by  pronouncing  the 
fault,  in  many  of  the  cases,  to  be  rather  with  the  surgeon  than  his 
case.  Section  of  a  nerve  is  only  justified  where  on  the  peripheral 
side  there  exists  a  lesion  which  may  not  otherwise  be  cured ;  and  of 
such  cases  there  are,  without  doubt,  many. 


RESECTIONS  OF  THE  MAXILLARY  BOXES 


691 


Section  of  Inferior  llaxillary  Nerve.— While  I  am  very  well 
convinced  that  in  many  of  the  reported  cases  sections  of  the  inferior 
maxillary  nerve  have  been  made  without  necessity,  yet  it  is  certainly 
an  operation  to  be  practiced  and  commended. 

In  looking  at  Fig.  120,  the  nerve,  which  is  a  cord  of  some  size,  is 
seen  to  pass  v^ithin  the  substance  of  the  jaw  midway  to  the  thick- 
ness, and  on  a  line  which  would  be  well  enough  marked  by  taking 
the  center  between  the  base  of  the  bone  and  the  cutting  edges  of  the 
teeth.  Approaching  the  ramus,  it  ascends  obliquely  upward  and 
backward,  escaping  operative  proceeding  at  the  posterior  dental  for- 
amen. 

To  expose  this  nerve,  if  within  the  ramus,  begin  an  incision  at  the 
sigmoid  notch,  and  carry  it  carefully  downward  through  the  integu- 
ments, avoiding  with  all  care  the  wounding  of  any  overlying  part  of 
the  parotid  gland;  the  gland  discovered,  push  it  carefully  backward, 
and  complete  the  incision  down  to  the  bone,  scraping  aside,  rather 
than  removing,  the  periosteum.  As  the  next  step,  take  a  small  tre- 
phine, and  cut  out  two  sections,  or  rather  cut,  with  the  trephine, 
sufficiently  deep  to  reach,  or  very  nearly  reach,  the  nerve  canal. 
Take  now  the  chisel,  and  with  gentle  cuts  remove  the  intervening 
portion  of  bone.  If  the  operation  is  carefully  performed,  the  nerve 
can  be  uncovered  without  the  slightest  wound.  Reaching  the  ves- 
sels, isolate  the  nerve  from  the  artery  and  vein  by  lifting  it  upon 
the  tenaculum.  It  is  now  to  be  divided,  removing  as  much  as  is 
thought  desirable,  never  less  than  half  an  inch,  and  if  more,  cer- 
tainly the  better. 

If  the  operation  is  to  be  performed  within  the  body  proper  of  the 
bone,  the  uncovering  is  even  more  simple :  use  still  the  straight  line, 
cutting  midway  upon  the  bone,  separate  the  lips  of  the  wound  by 
delicate  retractors,  securing  a  free  exposure  of  the  bone  (with  the 
periosteum  scraped  away,  as  before  suggested),  trephine,  and  re- 
move the  section. 

The  facial  artery,  it  is  not  to  be  forgotten,  passes  in  front  of  the 
masseter  muscle;  if  it  is  necessarily  cut,  the  operator  must  stop  and 
throw  a  ligature  about  it,— it  is  better  to  tie  both  ends.  Cuts  into 
the  muscular  substance  are  to  be  avoided  as  much  as  possible ;  such 
incisions  add  to  the  trouble  of  an  operation  by  the  free  hemorrhage 
provoked. 

A  section  of  the  nerve  cord  secured,  the  surgeon  carefully  lays 
back  the  flaps  and  watches  the  result.  It  has  been  thought  well  by 
some  to  give  large  doses  of  some  opiate  immediately  after  such 


692  ORAL  DISEASES  AXD  SURGERY. 

operations;  but  when  this  is  required  I  infer  the  operation  will  be 
found  to  prove  a  mistake,  as  in  such  successful  cases  as  have  occurred 
in  my  own  experience,  the  relief  from  suffering  experienced  has  acted 
a!3  the  profoundcst  of  opiates, — the  patients  sleeping  for  the  first  few 
days  almost  continually. 

Among  the  recorded  cases  of  section  of  the  inferior  dental  nerve 
where  complete  success  has  attended  the  operation,  are  four  by  Prof. 
Gross.  In  these  cases  all  known  remedies  for  the  relief  of  the  dis- 
ease had  been  employed  without  avail. 

Inversion  and  Eversign  of  Lip. — It  sometimes  happens  that 
from  accident  or  congenital  defect  the  lip — generally  the  lower — 
is  inverted  or  everted.  When  turned  inward,  the  part  is  shortened, 
and  not  unfrequently  permits  of  the  escape  of  the  oral  fluids.  In- 
version, while  generally  the  result  of  some  cancroid  affection  which 
has  produced  considerable  cicatricial  tissue,  is  yet  occasionally  ob- 
served associated  with  some  perversion  of  the  frsenum,  this  fold  being 
unduly  short,  or  running  too  near  the  free  edge  of  the  lip.  A  case  of 
inversion,  the  worst  I  have  ever  met  with,  resulted  from  a  gunshot 
wound,  involving  both  lip  and  jaw.  In  this  case  that  surface  which 
was  the  free  edge  had  become  involved  in  reparative  material  near 
the  base  of  the  alveolar  process,  and  had  thus  become  tightly  bound 
to  these  parts ;  the  teeth  and  face  of  the  gums  being  exposed.  To 
prevent  the  dribblings  from  his  mouth  passing  to  the  neck  and  breast 
the  patient  had  constructed  for  himself  a  species  of  tin  cup,  which 
he  constantly  wore  bound  to  his  chin,  and  which  was  concealed 
from  observation  by  a  large  neckkerchief. 

Eversion,  the  more  common  condition,  depends,  like  inversion,  on 
a  variety  of  causes.  A  burn  received  about  the  chin,  contracting 
the  part,  has  frequently  produced  it.  Hypertrophy  of  the  mucous 
membrane  is  an  occasional  cause;  preternatural  elongation  of  the 
fraenum  permits  such  falling  outward.  Any  loss  of  substance  ex- 
ternally, contracting  the  parts,  necessarily  tends  to  eversion. 

Treatment  of  inversion  or  eversion  varies,  of  course,  with  the 
various  causes.  In  the  inversion  of  the  lip  where  such  cause  lies  in 
the  existence  of  cicatricial  tissue,  it  will  be  found  easier  to  imagine 
than  to  secure  the  means  of  cure.  If  the  lip  has  length,  a  cure  may 
be  attempted  by  an  elliptical  portion  taken  from  the  outer  surface, 
the  parts  being  brought  together  and  an  immediate  union  secured 
through  the  use  of  the  hare-lip  pin  or  common  interrupted  suture; 
if,  on  the  contrary,  the  lip  has  been  shortened  in  its  bulk,  as  is  fre- 
quently the  case  where  the  ulcer  has  been  deep,  we  must  depend  for 


BESECTIONS   OF  THE  MAXILLARY  BONES.       693 

relief  on  aplastic  operation:  such  an  operation  consists  in  cutting 
away  the  cicatrix  and  transplanting  to  the  scat  of  removal  a  pcdi- 
celed  flap  taken  from  the  inner  face  of  the  cheek;  this,  however,  is 
always  more  or  less  unsatisfactory,  such  inversion  being  the  worst 
form  to  treat. 

A  shortened  or  improperly  attached  frtenum  is,  generally,  most 
easy  of  correction, — a  section,  yiore  or  less  extensive,  assisted  bv  a 
frequent  turning  outward  of  the  parts  by  the  patient,  quickly  result- 
ing in  the  cure. 

Inversion  from  gunshot  injuries  classifies  itself  with  contraction 
from  ulceration ;  each  case  is  a  study  in  itself,  and  will  be  found  to 
have  its  own  peculiar  demands.  Many  of  these  conditions  have  no 
cure,  the  patient  being  doomed  to  drag  through  an  undesirable  ex- 
istence. Others  will  be  found  very  easy  of  remedy,  some  attached 
point  requiring,  perhaps,  alone  to  be  freed.  Ah  intermediate  class, 
and  this  is  by  far  the  most  common,  demands  a  combination  of  oper- 
ations,— such  requirements  suggesting  themselves  to  the  ingenious 
surgeon.  . 

Eversions  are  treated  on  the  same  general  principles.  An  ellipsis 
from  the  mucous  face  of  the  lip  is  the  most  common  mode  of  cure 
resorted  to.  A  second  mode  is  a  double  V-shaped  incision,  the  cen- 
ter of  the  cut  being  the  center  of  the  lip;  the  space  within,  being 
wider  than  that  without,  naturally  draws  the  parts  inward  and  down- 
ward. In  preternatural  elongation  of  the  fraenum  I  have  secured 
satisfactory  results  by  cutting  out  a  limited  portion  of  the  bridle 
and  producing  an  eschar  by  the  use  of  nitrate  of  silver.  Or,  if  the 
operator  prefer,  he  may  stitch  the  parts  together  after  the  abbrevia- 
tion, securing  the  continuance  of  an  approxinuition  by  the  use  of  a 
turn  or  two  of  a  bandage. 


INDEX. 


Abscess,  alveolar 140 

abortive  treatment  of 141 

anomalies  of 142 

associations  of 143 

local  features  of. 140 

Absorption  of  gums 212 

Acute  inflammation  of  tongue...  582 

Adenoid  tumors 409 

Air  tubes 277 

Alveolar  process 19 

relations  of  teeth  to 20 

uses  of 22 

weakness  of 19 

Amalgam 193 

Anaesthesia,  general 242 

age,  its  connection  with 259 

cerebral  disease 263 

chloroform 253 

disease  of  heart 261 

effects  of  a  bad  article 249 

ether 243 

hysteria 260 

induction  of  insensibility....  257 

insanity 264 

manner  of  exhibition 253 

mode  of  exhibition  of 244 

nitrous  oxide  gas 265 

quantit}-  to  be  given 249 

relations  to  atmosphere 250 

strength  and  debility 260 

test  of  purity 253 

use  of  in  oral  surgery 253 

Anaesthesia,  local 288 

apparatus  of  Richardson 239 

"         for  foot 241 

«'         for  hand 210 

"         of  Thornwaite  and 

Home 238 

electro-galvanism 239 

ether  spray 239 

rhigolene 241 

use  of  ice  bags 238 

Analvsis  of  Indian-corn 183 

6{  milk 178 

of  oatmeal 179 

of  potatoes 179 

of  wheat 182 


Angina  simplex 97 

chronic 99 

Anomalies  of  dentition 116 

illustrations  of 127 

varieties  of 116 

Antrum  of  Highmore 21 

distention  of 422 

dropsy  of 424 

general  consideration  of 419 

■    indolent  tumor  of 420 

mercurial  troubles  of 433 

purulent  condition  of 425 

relations  of  temperaments  to  425 

scorbutic  troubles  of 433 

surgical  features  of. 22 

syphilitic  troubles  of 433 

tooth  abscess  of 422 

tumors  of 371 

Aphtha 600 

definition  of  by  Prof.  Wood  615 

diagnosis  of 614 

forms  of 601 

general  consideration  of 602 

prognosis  of 615 

review  of 605 

type  of 600 

Arterial  tumors 411 

Arteries  of  face 46 

branches  of  facial 47 

facial 47 

features  to  be  noticed 48 

of  tongue 57 

Articulation,  temporo-maxillary     61 

Associative  lesions  of  dentition...  88 
Atlee's  suture 538 

Bandages,  Barton's 515 

crossed  or  knotted 474 

Gibson's 517 

the  yard ^17 

Bean's  splint 520 

Benign  tumors 328 

Bites  of  insects 589 

Blood,  composition  of 172 

Bonos,  ethmoid 34 

hyoid 43 

(695) 


696 


INDEX. 


Bones,  lachrymal 42 

malar 41 

maxillary  superior 21 

■  "          inferior 20 

nasal 40 

palate 20 

sphenoid 3(j 

turbinated 32 

vomer 31 

Brushes,  improper  use  of 289 

CALCTJLtrs,  salivary 213 

illustrative  cases 210 

Caries  of  maxilla 303 

affinitj-  for  cellular  tissue 305 

constitutional  treatment  of...  107 

general  consideration  of 103 

local  treatment  of 187 

of  teeth 163 

paper  by  Dr.  Paul  on  predis- 
posing causes  of. IGG 

peculiarities  of. 306 

scrofulous  association  of 304 

treatment  of 306 

Carotid  arteries 48 

Character  of  oral  hemorrhage....  413 

Chisels  used  in  dentistrv 188 

Chloroform ". 252 

action  of 253 

at  ditferent  temperatures 254 

in  cerebral  diseases 203 

in  heart  diseases 261 

in  hysterics 200 

in  lung  diseases 261 

in  pregnancy  and  menstrua- 

tionX 261 

in  reference  to  age 259 

objections  to 255 

strength  and  debility 200 

tests  of. 252 

Classification  of  tumors 374 

Cleft  palate 633 

Cobweb  in  hemorrhage 92 

Comparison  of  nutritive  elements  178 

Compound  cystic  tumors 334 

Congenital  fissure  of  hard  palate  635 

Congenital  hare-lip 634 

Congenital  hypertrophy  of  gums  205 

Congenital  union  of  gums 298 

Congestion  of  nerve  centers 108 

Constitutional  considerations  of 

neuralgia 438 

Constitutional  treatment  of  hem- 
orrhage    92 

Contraction  of  lips 548 

Cow's  milk.... 113 

Crowded  dental  arch 289 

Cutaneous  hypersemia Ill 

Cystic  tumor  of  tongue 580 

Cysts  of  antrum 349 


Dental  arch 289 

Dental  chisels 188 

Dental  necrosis 310 

Dentifrices,  improper  use  of 289 

Dentigorous  tumors 337 

Dentition,  associative  lesions  of..     88 
changes  in  deciduous  teeth...  .  86 

diarrhoja  from 102 

irritative  fever  from 100 

miliv  teeth 79 

new  views  of 82 

observations      of      Goodsir, 

Todd,  and  Bowman 80 

periods  of  eruption  of  per- 
manent teeth 86 

skin  eruptions  from  110 

spasms  from  .., 106 

stomatitis  from 90 

Denudation  of  teeth 221 

Depressor  muscles 45 

Dewar's  compressor 539 

Diagnosis  of  necrosis 506 

Diai-rhcea 102 

DietFenbach's  rubber  stud 053 

operation  upon  lips 548 

DiflTerential  diagnosis  of  tumors..  390 
Dislocation  asscjciated  with  frac- 
ture of  jaw...... 527 

Dislocation  of  jaw 524 

condition  of  parts  in 525 

diagnosis  of 525 

kinds  of  luxations 524 

treatment  of 527 

Division  of  skin  diseases 113 

Double  hare-lip 543 

modification  of 545 

Duration  of  shock 477 

Effusions  into  structure  of  the 

tongue 588 

Elevators  for  removing  teeth 229 

Epithelioma 395 

illustrative  cases 396 

locations  of. 395 

views  of  Prof.  H.  H.  Smith.  399 

Epulic  tumors 362 

Erectile  tumors  of  tongue 589 

Eruptions  on  skin 110 

from  dental  irritation 112 

Erysipelas  of  tongue 588 

Ether 243 

effects  of  bad  article 249 

mode  of  exhibition 244 

relations  of  atmosphere  to...  250 

quantity  to  be  given 249 

Ethmoid  bone 34 

Exanthematous  necrosis 322 

Excavators,  hatchet 190 

hoe 190 


INDEX. 


697 


Eversion  of  lip 692 

Excision  of  tongue 592 

Face,  arteries  of 46 

bones  forming  orbit 18 

cellular  fascia  of 4o 

lateral  aspect  of. 17 

muscles  of. 4o 

nerves  of 49 

veins  of .50 

Favices,  isthmus  of 53 

parts  bounding 53 

Febrifuge 209 

Fergusson's  view  of  bare-lip 532 

Fever,  irritative *. 100 

Fissure  of  soft  palate 638 

Fistule,  salivary 267 

character  of. 267 

example  of 267 

treatment  of. 268 

Files < 189 

Filling  teeth 192 

instruments  used  for 195 

materials  used  for 192 

Fissures  of  hard  palate 633 

Follicular  inflammation 616 

Food,  animal 175 

vegetable 175 

Foot-spra}^  instrument 241 

Foramen,  infraorbital 19 

mental 19 

Forceps  for  extracting  teeth,  225,  238 

Foreign  bodies  in  nose 508 

Formation  of  mouth 52 

Forms  of  aphthae 601 

Fossfe,  canine 19 

incisive 20 

of  tongue 58 

Fractures  of  maxillary  bones 510 

bandages  used  in 516 

Barton's  bandage 515 

Bean's  splint 520 

Gibson's  bandage 516 

Gunning's  dressings "577 

gunshot 532 

modes  of  dressing 516 

of  alveolar  process 234 

symptoms  of. 550 

the  yard  bandage 517 

Functional  expressions  of  tongue.  563 

Ganglia,  Gasserian 72 

Meckel's 73 

naso-palatine 74 

ophthalmic 72 

otic 74 

submaxillary 75 

Gangrene  of  tonsils 276 


Gangrrena  oris (519 

Garangeot's  obturator 677 

Gibson's  bandge 516 

Glands,  parotid ,59 

sublingual 60 

subrnaxillarj^ 59 

tonsil 272 

Glotti^^,  oedema  of ;. '  278 

Gold,  leaf  and  crystal 192 

Goodsir's    observations   on   den- 
tition      80 

Gout 436 

Gums,  their  diseases 280 

accumulations  of  tartar 281 

artificial    teeth    improperly 

inserted 292 

congenital  union  of 298 

crowded  dental  arch 289 

dead  and  loose  teeth  289 

lancing  of 298 

malignant  impressions 90 

mercurial  impressions 282 

periodontitis 282 

scorbutic  impressions 284 

vulcanite  impressions 294 

Gunning's  dressings 517 

Gunshot  fractures 532 

Gutta-percha 194 

Hare-lip 531 

Bransby  Cooper's  views 532 

condition  of  patient 531 

Dupuytren's  views 532 

Dr.  Houston's  views 532 

Dr.  J.  M.  Warren's  views...  533 
general  view  of  operation....   531 

mode  of  operating 531 

Mr.  Fergusson's  views 532 

Prof.  Colles's  views 633 

"     D.  H.  Agnew's  views.  534 

"     Gross's  views 534 

"     H.  H.  Smith's  views...  534 

<'     Pancoast's  views 534 

time  of  life  best  suited  for 

operation 531 

views  of  Skey 532 

"     Velpeau 532 

Hemorrhage,  arterial 473 

after  extracting  teeth 235 

capillary 473 

treatment  by  acupressure....  473 
"  by  alum-water. ...  474 

"  by  cold  water 474 

"          by  Monsel's  solu- 
tion   474 

"  by     opium     and 

lead 474 

"  by  pad  and  band- 

'age 473 


698 


INDEX. 


Hemorrhage,  arterial,  treatment 
by  tinct.  Erigeron  Cana- 

dense 474 

"  by  torsion 473 

"  of  by  ligation 473 

venous 473 

Hoe  excavators I'JO 

Hoey's  clamp 635 

Holes  in  palate 649 

Hyoid  bone 42 

Hyperostosis 357 

Hypertrophy  of  gum 395 

Hypertrophy  of  tongue 591 

Hysteria.....". 260 


Illtjstkations  in  epithelioma...  896 

Insanity  in  relation  Avith  ether...  264 
Induction    of    insensibility     by 

anesthetics 257 

Inversion  of  lip 692 

Irritable  aphthae 617 

Isthmus  of  fauces 53 

Lachrymal  bones 42 

canal 19 

inflammation  of 19 

Lateral  aspect  of  face 17 

Lepidoid  growths 415 

Lips 531 

eversion  of 692 

inversion  of 692 

hare 531 

treatment  for 536 

Luxation  of  inferior  maxilla 524 

congenital 527 

condition  of  parts  in 525 

diagnosis  of 525 

kinds  of 524 

treatment  of 527 

Malar  bones 41 

process  of  maxilla 23 

Maxilla,  superior 21 

caries  of 304 

cases  by  Delamotte,  Koberts, 

and  Heath 527 

causes  of 525 

condition  of  parts  in 525 

congenital  luxations 527 

diagnosis  of 525 

difficulty  of  replacing  when 

of  longstanding 526 

discoloration  associated  with 

fracture 527 

dislocation  of 524 

fracture  of 510 

fractures  of 512 


Maxilla,  gunshot  injuries  of 513 

inferior 26 

manner  of  reducing 528 

subluxations 526 

Stromej'er's  forceps 528 

treatment  of 513 

treatment  of  luxations 527 

use  of  anuesthetics  in 529 

Maxillary  fractures 510 

Mechanical  surgery 652 

Meckel's  ganglion 73 

Melanoid  carcinoma 388 

Mental  foramen 19 

Mercurial  impressions 282 

necrosis 325 

ulcers 503 

Metastatic  disease  of  tongue 590 

Milk 173 

cow's 173 

mare's 186 

woman's 170 

Monsel's  solution 237 

Mouth,  the 44 

bones  forming  roof  of 45 

formation  of 52 

instrument  for  stretching....  553 

naucous  membrane  of. 58 

Mutter's    operation   for  en- 
largement of 550 

offices  of 44 

organs  contained  in 44 

sectional  expression  of 58 

soft  parts  of. 45 

Myeloid  tumors 876 

microscopical  appearance  of.  877 


Nasal  bone 40 

Necrosis 809 

alveolar 312 

dental 310 

exanthematous 822 

mercurial 825 

phosphor 813 

syphilitic 320 

Nerves,  fifth  pair 63 

facial 49 

Neuralgia 435 

a  phenomenon  and  not  a  dis- 
ease    436 

character  of  pain , 435 

constitutional  character  of...  438 
difference  between  rheuma- 
tism and  neuralgia 435 

illustrations 441  to  471 

malarial  relations 487 

predisposing  causes  of 439 

syphilitical  relations 437 

i  Nitrous  oxide  gas 265 


INDEX. 


699 


Nutrition 174 

Nutritive  elements 178 

Obturators 652 

construction  of. 657 

Dieffenbach's  rubber  stud....   653 

fixing  of  in  mouth 638 

illustrative  cases 659 

Kingsley's 678 

principles  of 652 

Steam's 678 

Odontalgia 201 

continementof  gas  and  pus  in 

pulp  cavity 209 

deposits  of  osteo-dentine  in 

pulp  cavity 210 

diseased  state    of    periodon- 

teum 208 

for  direct  or  indirectexposure 

of  pulp 202 

for  sensitive  dentine 201 

recession  and  absorption  of 

gums  and  alveolus 212 

sympathy 212 

treatment  of 202  to  212 

Odontocele 334 

(Edema  of  glottis 278 

Operations  on  lips  and  cheek 548 

Osteo-carcinoma 386 

derivation  of  term 386 

diagnostic  differences  be- 
tween carcinoma  and  sar- 
coma   390 

svnonyms  of 389 

treatment  of 392 

Osteo-plastic  or  tooth-bone 194 

Osteo-sarcoma 371 

derivation  of  term 371 

its  applicability  as  a  noun  of 

multitude 371 

Ozaena,  causes  of 497 

associations  of  508 

constitutional  treatment  of...   507 

diagnosis  of 506 

local  treatment  of 507 

Palate  bone 29 

Palate,  holes  in 649 

treatment  of 649 

Palatine  defects,  and  their  treat- 
ment   633 

Papilla  of  tongue 56 

Parasite  of  aphtha' 616 

Pare's  obturator 677 

Parotid  fistule 259 

gland 59 

tumor 541 

Periodontitis 202 


Periods  of  eruption  of  permanent 

teeth 86 

Pharyngitis *.]."  301 

Pharynx 53 

Phosphor-necrosis 319 

Plastic  operations 556 

Predisposing  causes  of  neuralgia  439 
Pressure   in   treatment    of   cleft 

palate 635 

Prognosis  of  shock 480 

Ranula 621 

character  of 621 

common  illustrations  of 627 

curious  case  of 623 

Recession  of  gums 212 

Remarks  on  extracting  teeth 234 

fractures  of  alveolar  process.  234 

hemorrhage  from 235 

local  anajsthetics  used 238 

luxation  of  jaw  from 238 

reduction  of  luxated  jaw 528 

Resection  of  maxillary  bones 679 

Deaderick's  operations 689 

Horner's  operations 681 

of  both  superior  maxilla 685 

of  inferior  maxilla 687 

Rhigolene 241 

Saliva,  analysis  of 213 

Salivary  calculus 213 

Scirrhus  carcinoma 386 

of  tongue 575 

Screw  for  removing  tooth-roots..  231 

Scurvy 284 

treatment  of 284 

Sebaceous  tumors 405 

Secondary  cyst  of  antrum 351 

Sectional  expression  of  mouth....     52 
Section    of    inferior     maxillary 

nerve 691 

Sequestrum  after  measles 323 

Shock,  primary  and  secondary...  474 

importance  of  diagnosis 475 

views  of  Prof.  H.  H.  Smith 

on 475 

Skin  diseases,  varieties  of. 112 

Skull,  front  and  lateral  regions  of.     18 

Spasms 106 

for  congestion  of  nerve  cen- 
ters   108 

from  dental  irritation 107 

Sphenoid  bone 37 

Spray  of  ether 239 

Staphyloraphy.   038 

anatomical  study  of  part 039 

literature  of 042 

preparation  of  patient  for....  638 


700 


INDEX. 


Staphyloraphy,  stages  of  opera- 
tion    G42 

Steam's  obturator 678 

Stomatitis,  sj^philitic D-1 

Styptics 'Xl 

Sublingual  glands (JO 

Submaxillary  glands 59 

Superior  maxillary  nerve 67 

Swallowing  of  tongue 599 

Symptoms  of  maxillary  fracture.     50 

Syphilitic  diseases  of  gums 288 

neuralgia 437 

Tartar 210 

Teeth 289 

agents  that  destroy 290 

anomalous  or  deformed 232 

artificial 292 

composition  of. 165-170 

diseases  of. 140-201 

first,  or  milk  set 

Thrush,  treatment  of CIS 

Tin  foil 193 

Tongue 54 

acute  inflammation  of 582 

arteries  of 57 

character  of 44 

cystic  tumors  of 580 

elfusions  into 588 

erectile,  tumors  of 589 

erysipelas  of 588 

excision  of 592 

fatt_y  tumors  of 590 

forms  of 597 

fossa  and  base  of 58 

functional  expression  of 562 

furred  condition  of 565 

hypertrophy  of 591 

insects,  bites  of 589 

mercurial  ulceration  of. 573 

metastatic  tumors  of. 590 

operations  for 599 

organic  diseases  of 568 

papilla  of 56 

scirrhus  of 575 

swallowing  of 599 

sympathetic  diseases  of 568 

temperature  of. 564 

tongue-tie ..  597 

uses  of 44 

view  of 55 


Tonsil  glands 272 

■  composition  of 2:54 

cystic  growths  of 276 

gangrene  of 276 

hypertrophy  of 274 

relation  of 254 

ulceration  of 276 

Tumors  of  mouth 327 

benign 328 

comjiound  cyst 334 

cyst  of  antrum 349 

degenerating  sarcoma 383 

epulides 362 

fungus  hajmatodes 387 

meianoid 388 

myeloid 376 

osteo-carcinoma 386 

osteo-dental 336 

osteo-sarcoma 371 

scirrhus  carcinoma 386 

secondary  cyst  of  antrum....  351 
simple  cystic 329 

Tumors  of  parts  associated  with 

the  mouth 405 

adenoid 409 

arterial 411 

cvstic 407 

fatty 408 

keloide 417 

lepidoid 415 

n.Tvi 411 

sebaceous 405 

venous 413 

verrucous 416 

Veins  of  face 51 

Vomer  bone 31 

Vulcanite  obturators GG9 

WiLDMAN  on  facial  defects 671 

Wounds,  of  mouth  and  associate 

parts 472 

character  of  hemorrhage 473 

hemorrhage  of. 473 

indications  in  treatment 472 

injurious  effects  of  Monsel's 

salts  in 479 

removal  of  foreign  particles.  472 

treatment  of 473 

varieties  of 472 


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By  Edward  C.  Seaton,  M.D.,  Medical  Inspector  to  the  Privy 
Council.     Illustrated.     12mo.     Cloth.     $2.25. 

First  Principles  of  Medicine. 

By  .Archibald  Billing,  M.D.,  A.M.,  F.R.S.  Sixth  edition, 
revised  and  improved.  8vo.  Cloth.  $0.00. 
•'We  know  of  no  book  which  contains  within  the  same  space  so 
much  valuable  information — the  result,  not  of  fanciful  theory,  nor 
of  idle  hypothesis,  but  of  close,  persevering,  clinical  observation, 
accompanied  with  much  soundness  of  judgment  and  extraordinary 
clinical  tact." — Medico- Chirurgical  Review. 

Medical  Diagnosis^ 

With  Special  Reference  to  Practical  Medicine.     A  Guide 
to  the  Knowledge  and  Discrimination  of  Diseases.     By  J- 
M.    Da    Costa,    M.D.      Second   edition.      Illustrated    with 
numerous  wood  engravings.     8vo.     Cloth.     $tj.(i0. 
The  aim  of  the  author  in  writing  this  book  was  to  furnish  ad- 
vanced students  and  young  graduates  of  medicine  wi'h  a  guide 
that  might  be  of  service  to  them  in  their  endeavors  to  discriminate 
disease. 


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